When Texas Went After Transgender Care, Part 1

[0] From New York Times, I'm Michael Bobaro.

[1] This is a daily.

[2] We're here and queer gay used to us.

[3] We're here.

[4] We're here.

[5] We're gay youth to us.

[6] In recent years, there's been a sharp increase in the number of younger Americans who identify as transgender and who are seeking therapeutic and medical intervention to support their transition.

[7] We gather here to raise up the voices of the transgender transgender transgender transgender.

[8] children who are in need of our protection.

[9] This has coincided with the escalating set of laws, being introduced in Republican statehouses across the country, aimed at trans youth, and seeking to block this sort of care from being provided.

[10] In the state of Arkansas, the state just became the first to ban gender -affirming medical care for transgender kids.

[11] A similar measure before North Carolina's General Assembly.

[12] Alabama became the third state in the country to pass laws restricting gender -affirming care for minors.

[13] And what makes what's happening in Florida look like child's play is what they're doing in Texas.

[14] Earlier this year, Governor Greg Abbott of Texas took it a step further.

[15] It's now investigating parents who are trying to provide gender -affirming care for their trans kids.

[16] Declaring that parents who sought this care for their children should be reported for child abuse.

[17] Today, in the first of two episodes, my colleague, Azeen Gureshi, has the story of one family in Texas who was seeking such care when the political storm hit.

[18] It's Wednesday, April 20th.

[19] Azine, tell us about the reporting that you have been doing and how that led you to this story.

[20] Sure.

[21] Sure.

[22] So I'm a reporter on the science desk, and I cover sex and gender.

[23] And for the past few months, I've been really focused on stories around medical care for trans kids, especially teens.

[24] And, you know, as we've seen this big increase in the number of teens seeking care, clinicians and researchers are in the middle of some really complex conversations about how best to treat them.

[25] You know, when should teens receive this care?

[26] What kind of criteria should they have to meet to start a transition?

[27] What do we know about how these kids might feel in the future?

[28] And, you know, it's honestly not a very easy moment to cover these conversations because, of course, this is coinciding with the politics around trans care reaching a real fever pitch.

[29] You know, this is arguably one of the most fraught issues in our culture right now.

[30] Right.

[31] And nowhere is all of this colliding more than in Texas, where the political situation is the most heated, it's the most polarized.

[32] and doctors, families, and teens are really caught in the middle of that and having to make medical decisions in the midst of a whole lot of turmoil and really hostility.

[33] And so following Governor Abbott's order, I started reaching out to providers and families on the ground in Texas, and that's how I met Grayson and Holly.

[34] Just to start, can you say your name and your age?

[35] My name is Grayson, and I'm...

[36] Currently 17.

[37] I'm turning 18 in December of this year.

[38] How about I'm Holly?

[39] I'm older than the hills.

[40] No, I'm 62.

[41] So Holly and Grayson are a mom and a son.

[42] She's a lawyer.

[43] He's a senior in high school.

[44] They live in the Dallas -Fort Worth area, but Holly's originally from New York, which she points out often.

[45] What brought you to Texas?

[46] Why the heck am I here?

[47] I followed my ex.

[48] I moved to Texas because my ex wanted to come home to Texas and was from here.

[49] She talks a lot about the culture shocks.

[50] So people used to ask me, when was I born?

[51] And I thought they meant my age, but they did not.

[52] They meant when would I actually accept Jesus Christ is my Lord and Savior.

[53] And that, That was a cultural shock.

[54] What kept you in Texas?

[55] Oh, my kids, after they were born.

[56] So Grayson and his twin sister were both born in Dallas.

[57] And not long after that, Holly and Grayson's biological mom, Heather, separated.

[58] But Holly said that leaving Texas wasn't really an option.

[59] We couldn't get legally married, so there's no, you know, formal custody agreement.

[60] There's no anything.

[61] So I didn't want to give up my time with my kids.

[62] kids.

[63] And I knew she wouldn't go to move back to New York.

[64] I mean, what were my options?

[65] That's why I'm here.

[66] And I will remain here as long as my kids are here.

[67] What was Grayson like as a kid?

[68] How would you describe him when he was growing up?

[69] Grayson was always outgoing, friendly, had always had friends.

[70] Growing up, Holly remembers Grayson is a pretty happy kid.

[71] But then around middle school, she started to notice that Grayson was acting a little different.

[72] Yeah, it just started to get a little more introverted.

[73] Middle school was really difficult for him, and he definitely went a lot inside himself.

[74] It did get a little bit concerning at some point when he really started to kind of self -isolate.

[75] What do you mean?

[76] I mean, come out for dinner and stuff, but he seemed to spend an ordinate amount of time in his room alone.

[77] And that was concerning, you know, because it was a change of behavior.

[78] It was a change.

[79] So, you know, I was kind of worried about it.

[80] I would say he was wilting.

[81] He seemed to be wilting.

[82] Holly says Grayson wouldn't open up to her or Heather about what was going on.

[83] So they asked if he'd be willing to go to counseling, and he said yes.

[84] And the counselor basically called us after a while and said, I can't help you.

[85] He won't open up to me. He won't tell me what's going on.

[86] You know, this isn't working.

[87] Then they take him to see some doctors.

[88] We tried a psychiatrist who prescribed medication.

[89] He was on medication for a period of time.

[90] That didn't work.

[91] We talked to the pediatrician.

[92] You know, we were trying pretty much everything we could think of to help this kid.

[93] Because he was definitely not doing well.

[94] And then, You know, I did snip some and did find some drawings that were concerning to me. Holly finds some drawings that Grayson had done.

[95] I saw drawing on, it was a picture.

[96] It was almost like a stick figure face.

[97] But it had duct tape across the mouth.

[98] And it was captioned imposter and not worthy.

[99] and then there was another one that said liar and then there was one that was had a comb and was combing the hair but there were drops of blood coming from the head I still don't know what that means but it took my breath away took my breath away the air in the room left when I saw those I felt a void of ever.

[100] I don't know how else to describe it.

[101] How old was he at that point?

[102] 14 -ish.

[103] And I remember feeling cold.

[104] Like physically cold?

[105] Physically cold.

[106] I was worried about suicide.

[107] I mean, I'm going to be honest.

[108] I was very worried about he was going to a very dark place.

[109] and nothing was really helping.

[110] So I was worried, you know, teen suicide.

[111] I mean, you hear about it all the time, and I was concerned about that.

[112] And then finally, one day, Grayson came to the dinner table needing to talk.

[113] And he and Holly told me this story together.

[114] You know, I always forced the kids to eat dinner with me. Like, we were having family dinner, you know, and no phones.

[115] And I was just sitting there and I was like, gripping my fork with like, like, white -knuckled.

[116] He just looked like he was gathering his courage.

[117] And I was like, mom, I'm trans.

[118] And she's like, are you sure?

[119] And I'm like, yes.

[120] And she's like, okay.

[121] And then there's like silence for a little bit.

[122] And she was like, I, all right.

[123] So that's how he told me. Up until this point, Holly had thought of herself, as having twin daughters, and it thought of Grayson as the tomboy of the two.

[124] Now, Grayson was telling her, it's more than that, and that he'd been working through questions about his gender for a long time, ever since he was that young, bubbly kid.

[125] I was definitely a tomboy.

[126] I remember when I was really little, when my mom would drive me home from pre -K, I would, like, imagine myself as, like, a superhero in, like, a movie, but I would always notice that my hair was short in my head.

[127] And then when I got older, I would look at myself in the mirror.

[128] I would hold my hair back and be like, do I like it if I have short hair?

[129] Would I like it that way?

[130] And then when I did it, I was like, oh, I think I really like this.

[131] But then that soon kind of became like not enough.

[132] And that feeling intensified as Grayson started going through puberty.

[133] And his body started changing in ways that he couldn't mask the way he'd been doing before.

[134] I could see myself in the bathroom mirror and I like look at my chest, which like at that point was like really starting to form.

[135] And I was like, wow, I don't like this.

[136] I don't want this on my body.

[137] I knew that having breasts or having wide hips would make people look at me like I was a girl and I wanted them to view me as masculine and like the tomboy that I used to be perceived as.

[138] And it's around this time that a friend came out to Grayson as non -binary, meaning they didn't identify as being a boy or a girl.

[139] And Grayson started thinking about his own gender identity.

[140] He Googled terms like gender queer and transgender, and he really connected with what he was reading.

[141] He felt like it sort of described what he was feeling at the time.

[142] But he wasn't ready to accept it.

[143] And the people I surrounded myself with really did not help because they knew.

[144] like other trans kids at our school and they always were like oh they're looking for attention and basically i don't know why but i listened to them and i was like yeah maybe i'm just looking for attention and i'd be looking for attention if i told anyone so for a really long time i kept it to myself i remember vividly that like every single night i've come home so sad i didn't know why and then i just start to cry when i got to my room and i would i would do that I would cry for a while, then I would get up and I would do homework, and then I'd cry again, and then I'd go eat dinner and act like everything was normal.

[145] And when I was around my family, I would be like, yes, I'm who you think I am.

[146] And then I would go back in my room, and I'd cry because I was lying to everyone in my life.

[147] And so that's how they get to that moment at the dinner table when Grayson tells Holly what's going on.

[148] How did you feel hearing that?

[149] surprise and relief I was surprised because my own bias as a lesbian I thought that my daughter was probably a butch lesbian and that's why she was such a tomboy so I was surprised to hear it was a gender identity thing but I was also relieved because a lot made sense then Holly says this took her back to her own experience coming out to her parents decades earlier.

[150] And on the one hand...

[151] I'm sure it's how my parents felt when I told them I was gay.

[152] It's probably exactly the same feeling.

[153] It gave her some understanding of what her parents had struggled with.

[154] But on the other hand, it made her want to react differently to Grayson than they had reacted to her.

[155] I think maybe because, maybe because I'd had the experience myself of not living as who I was and having to hide, I didn't want that for my son because I knew how difficult it was.

[156] Maybe, maybe that's part of it.

[157] I don't know.

[158] But I know that that feeling is just so awful and you feel like you're lying to people and it's just very difficult.

[159] So maybe because I had the experience, I was more, you know, you know, You know, I did want a different experience for my child than I had for myself.

[160] And so Grayson remembers her telling him that moment at the dinner table.

[161] Yes, it's perfectly fine.

[162] And I love you regardless.

[163] So Holly goes to Grayson's pediatrician with this information.

[164] And the pediatrician tells her about a clinic in Dallas called Genesis that might be able to support Grayson.

[165] Hmm.

[166] I'm interested to hear that a clinic like this existed in Dallas, Texas.

[167] Yeah, well, it's interesting.

[168] So when Genesis opened back in 2014, it was the only youth gender clinic in the entire Southwest.

[169] And it was opened after this pediatric endocrinologist, Jimena Lopez, saw her first trans patient.

[170] And this kid was really struggling with starting to go through puberty.

[171] They were really depressed.

[172] And so she went, you know, across the country and asked different specialists, you know, how can I best support this kid?

[173] And, and And this was around the time that medical consensus was really starting to crystallize around the value of this sort of care for trans kids.

[174] And so Dr. Lopez brought that back home.

[175] And once she started providing that treatment to the kid, she was really shocked at how quickly the kid turned around emotionally.

[176] And, you know, word got around that she was providing this type of care.

[177] And soon she was seeing five patients, 10 patients, 50 patients.

[178] And so at some point, Dr. Lopez approaches the Children's Hospital at the University of Texas Southwestern Medical Center, which is a public institution, and makes the case for the creation of this new center to be based there.

[179] And the university was essentially like, sure, they weren't going to broadcast the work that they were doing necessarily, but they were okay with her moving forward with what she had proposed.

[180] And over the next few years, the clinic starts to build up dozens and then hundreds.

[181] of patients in Texas.

[182] And it becomes a place that's known for really being supportive of kids who want to transition and for being one of the early places to publish research about how their patients are doing as time goes on.

[183] And so when Grayson's pediatrician hears from Holly, it's really the obvious place to recommend that they go.

[184] How did you feel the moment you heard about Genesis?

[185] I had up to that point not known.

[186] that it had existed.

[187] So it was like a light bulb went off.

[188] I was like, oh, this is my chance.

[189] And for Grayson and Holly, it's feeling like the beginning of an answer.

[190] We'll be right back.

[191] Okay, so, Azeen, what happens once Holly and Grayson find out about Genesis?

[192] So in 2019, after they'd been waiting something like two months for an appointment, Grayson and Holly are finally on their way to their first appointment at Genesis.

[193] And, you know, as they're walking through the front doors, Grayson is really excited.

[194] It was like almost like nervous excitement.

[195] Felt sterile to me. Holly is more nervous.

[196] So it was a little unsettling at first to walk into the clinic, not knowing what lay ahead, what this, what this appointment was going to be like, who would we be talking to, what would the questions be, what would the outcome be?

[197] And what happens at this first visit?

[198] So that first day at the clinic, they met with a psychologist for like three to four hours.

[199] Grayson sat down with them first and then Holly.

[200] And the main goal is to figure out how Grayson is experiencing his gender identity and how much he understands about what the options are to help him at this point.

[201] So the psychologist is asking him questions like, when did he start questioning his gender identity?

[202] what was childhood like?

[203] What's his experience been of his gender up to this point?

[204] Does he have distress about his body and how could he feel better about that?

[205] Has he struggled with his mental health?

[206] How is stuff going with school, with family, with friends?

[207] And also questions like, has he thought about going on hormones?

[208] Does he understand what changes that would cause?

[209] And does he understand that there is some chance, though it's thought to be pretty small, that he might change his mind down the line?

[210] Mm -hmm.

[211] And by the end of that first day, the psychologist got together with Holly and Grayson and told them that Grayson was exhibiting signs of what the psychologist called moderate to severe gender dysphoria.

[212] And that was causing him a lot of distress.

[213] Do you remember what that felt like to hear a label sort of put on what he was going through?

[214] Yes, I remember.

[215] I'm going to try to describe it.

[216] it's it's a mixed bag it was a little bit relieving but it was also startling in a sense because I'm not sure that we expected it although we knew it was a possibility hearing it out loud from a professional is a little different and it was a little scary at the same time as it was relieving but But it was definitely relieving, too.

[217] I know I use that word a lot, but I think the fact that I use a lot speaks to the amount of distress we were all feeling prior to this.

[218] Literally the same day, she sent us up to another floor where I met with the doctor and talked about potential paths that I could take for transitioning.

[219] So after this assessment, the next step is to talk about what sort of options are available to Grayson.

[220] And the clinic tells me that this depends on a range of factors, including how ready the family is to begin care and what kind of treatment they're looking for.

[221] You could try puberty blockers, you could try hormones, you could do nothing and, you know, hope is mental health improves, you could do counseling.

[222] We'd already gone the counseling route and counseling hadn't really helped at that point and medication that had been prescribed by a psychiatrist hadn't helped with the depression.

[223] That history left Holly feeling open to the possibility of a medical transition, which is what Grayson felt he wanted.

[224] But another factor that has to be considered is what stage of puberty a young person is at when they start this process.

[225] In Grayson's case, he had already gone through female puberty, so it was too late to take puberty blockers.

[226] Instead, they told him he could start hormone therapy, where he would take testosterone.

[227] And they gave us literature about hormone therapy and all the adverse side effects, positive side effects, which elements would be reversible, which elements are not reversible.

[228] actually most are fully reversible if you stop taking hormone therapy I believe the only one that wasn't was your voice yeah voice and I believe facial hair facial hair yes not reversible but of course there's always electrolysis and laser but medically I believe the only irreversible side effect at that point was a drop in the voice vocal cords changes would not be reversible.

[229] Were you guys worried at all about the reversible, irreversible stuff?

[230] I feel like for some parents, that's such a big issue, and for others it's not.

[231] It's a huge issue for many parents.

[232] I personally was not overly worried about that.

[233] I don't know about Grayson.

[234] I was looking forward to it.

[235] Yeah, right.

[236] Just a little bit, I'm not going to lie.

[237] I was kind of excited.

[238] I was kind of excited.

[239] I was for it, I wanted my voice to drop because I felt like it felt more normal.

[240] Right.

[241] Right.

[242] I remember being most concerned about the side effects that relate to the things that you normally think of for males, which is increased heart attack and, you know, the beer belly and, you know, all those sorts of things than I was about anything else.

[243] But they give you that information because it is of concern to some parents, probably most.

[244] Holly's saying that this discussion of the irreversible side effects, that it's probably of concern to most parents.

[245] What have you found in your reporting, Azeen?

[246] So it's really hard to quantify, you know, and obviously every family is different.

[247] But I would agree with Holly.

[248] You know, I definitely talk to a lot of families where they're really concerned about side effects.

[249] And what sorts of things are these parents concerned about?

[250] So two of the bigger concerns that come up a lot relate to the use of puberty blockers, which remember, Grayson didn't have to go on those because he'd already gone through puberty.

[251] Right.

[252] So the two big concerns that come up relate to bone health and fertility.

[253] So puberty is this time where your bone development really kicks into gear.

[254] Your bone density actually increases and you grow taller.

[255] But, you know, the whole point of puberty blocking drugs is to hit pause.

[256] And so that actually hits pause on that bone development as well.

[257] Now, the science that we do have, the vast majority of those studies have actually been conducted in a totally different patient population than trans kids.

[258] Most of those studies focus on, you know, this group of pretty young kids who have hormonal disorders where they might go through puberty as young as three years old and need to be put on blockers until they reach, you know, an age, be at 10 or 11, whatever, where they can.

[259] can be taken off those drugs and go through natural puberty.

[260] And for these kids, they're put on blockers and then, you know, once they go off, their bone density seems to recover.

[261] But what we don't really understand as well yet is what happens with trans teens.

[262] Trans teens go on blockers to delay their natural puberty and then go on hormone treatment to go through a different puberty, one that affirms their gender.

[263] And we just don't have a lot of data on what happens to bone density in those people long term.

[264] And what about fertility?

[265] Again, the science here is really early, but the concern is basically that by blocking puberty and then immediately transitioning to hormones, you could interfere with the maturation of eggs and sperm.

[266] And, you know, if a kid knows that they want to have children down the road and want to leave open the option of having their own biological kids, that permanent loss of fertility, you know, is a big deal.

[267] So these clinicians do coach the kids and their parents about what the options are if preserving fertility is important.

[268] And this is really a bigger issue for trans girls than trans boys.

[269] You know, because trans boys, they are assigned female at birth.

[270] And when they are born, they are born with all of the eggs that they will have for the rest of their lifetime.

[271] But for trans girls, they are assigned male at birth.

[272] and they actually don't develop sperm until puberty.

[273] So if preserving fertility is important for them, you know, endocrinologists will typically recommend that they wait to start on blockers until later in puberty so that they have a chance to bank sperm and leave open the option that they can have kids down the line.

[274] Got it.

[275] And so these are very serious considerations for families to think about.

[276] But, you know, in talking to a lot of the families who are considered, considering this care, often the biggest unknown is just, is this definitely the right thing for my kid?

[277] There's no blood test or anything that tells you, yes, your kid is definitely trans.

[278] It's all based on self -report.

[279] And sometimes that's difficult to gauge when there's other stuff going on, like serious mental health issues.

[280] And there's just very little in the way of long -term research following kids who get this care into adulthood to tell us how they did and how they felt about the medical decisions they made as teens.

[281] But, you know, trans advocates and clinicians say all the time that doing nothing is also doing something because forcing a child to go through the puberty of a gender they don't identify with can also be harmful.

[282] So I can't stress enough, you know, these can be really complicated and urgent decisions to make for families.

[283] And for Holly, it was really these larger questions that weighed on her, too.

[284] After she and Grayson leave the clinic, she and Grayson's other mom have a lot to process.

[285] And then we came home and did some serious reading of, you know, a variety of things, some literature that they had given us and some that we had found on our own from reliable sources and American Pediatrics Association and all of that and whether or not we should proceed with some kind of treatment for this or let it right or, you know, do you wait until the child's 18?

[286] It's a very scary position to be in.

[287] So we really tried to educate ourselves and ask other, other trans parents about their experiences and, you know, just learn as much as we can about it in order to make the most informed decision that we could about whether or not to consent to treatment.

[288] And to give your consent to a medical treatment for your child, no matter what kind of medical treatment, really, it's a big deal.

[289] So it was unsettling in the sense of self -doubt.

[290] What if we're wrong giving consent?

[291] Or worse yet, we don't give consent.

[292] And Grayson continues to have serious mental and emotional difficulties.

[293] And we were concerned about, you know, what he might do to himself.

[294] So this comes up a lot in conversations around trans young people and this medical care.

[295] Studies, including by the CDC, show that suicide risk among trans adolescents are much higher than in the general population.

[296] And Holly knows all this.

[297] And because his emotional and mental health was so fragile at that point.

[298] Because Grayson has been in so much pain.

[299] And we couldn't find any other explanation, really, and other treatments had failed.

[300] Your typical kind of counseling and medication had failed.

[301] So that was sort of it.

[302] Both Holly and her ex are largely on board at this point.

[303] So the family decides to move forward with hormone therapy.

[304] And almost right away, just having made the decision, Holly sees a change in Grayson.

[305] I started saying, seeing I just I started seeing the weight lift from his shoulders I just saw him he looked lighter and happier and more confident and more like a whole person than this fractured person that I had been seeing for such a long time it fit it just fit he seemed he seemed lighter like the weight of the world had been taken off his shoulders in a way.

[306] I was really happy.

[307] I told a lot of my friends, I was like, this is it.

[308] This is going to be like a turning point in my life.

[309] I'm so excited.

[310] And everyone was really happy for me, which was great.

[311] What did it feel when you started actually starting the treatment?

[312] At first, there wasn't really anything that changed because it takes a while.

[313] It's like around the three or four month mark that things actually.

[314] start to happen and your body starts to like react to hormones but it was very interesting um to see um fat slowly shift around my body it's like um because now like i have a bit of a gut not going to lie but i but i had like i stayed i stayed the same weight i always have it's just presenting in different places and um my voice started to drop i want to say around five or six months and it really sounded at first like it was like my voice was just strained but it was just my vocal cords going getting thicker and so um I was like yes I like this it's a little it was a little bit jarring to know that my voice was going down and then when my voice started cracking I was like okay that's a little embarrassing not going to learn so you're like going through puberty again yeah yeah Yeah.

[315] It's just, you get an out of community.

[316] Yes.

[317] Yeah.

[318] Grayson got to do it twice.

[319] We're lucky.

[320] So it's really not long after Grayson begins receiving care at Genesis that they're seeing this pretty meaningful impact.

[321] But this is also around the same time that Republican politicians in Texas are starting to notice this clinic and the type of care that it's providing.

[322] Tomorrow on the Daily.

[323] The story behind the Republican politicians.

[324] Republican efforts to shut down Genesis and the impact such efforts are having on the future of Transcare.

[325] We'll be right back.

[326] Here's what else you need to Notre Day.

[327] On Tuesday, Russia officially began what had called a new phase of its war on Ukraine, focused on capturing the country's east, known as the Dunmoss, without making the kind of blunders that have so far defined its invasion.

[328] But Ukrainian forces said they had already succeeded in repelling the new Russian offensive, destroying 10 tanks and 18 armored units in a series of clashes.

[329] And the day after a federal judge struck down a countrywide mask mandate for public transportation, the Biden administration sent mixed and confusing messages about its response.

[330] Mr. President, should people continue to wear masks on planes?

[331] That's up to them.

[332] Rather than defend the mandate, Biden said that Americans should decide for themselves whether to wear masks.

[333] But at the same time, the Justice Department said it was prepared to appeal the judge's ruling in order to reimpose the mask mandate.

[334] Today's episode was produced by Sydney Harbor, Chelsea Daniel, and Rachel Quester, with help from Eric Kruppke, Rob Zipko, Patricia Willens, and Jessica Chon.

[335] It was edited by Lisa Tovin and Lisa Chow.

[336] Contains original music by Alicia Baito, Dan Powell, and Marion Lazzano, and was engineered by Chris Wood.

[337] Our theme music is by Jim Brunberg and Ben Landsberg of Wonderly.

[338] Special thanks to Maddie Mascello and Virginia Hughes.

[339] That's it for the Daily.

[340] I'm Michael Bobaro.

[341] See you tomorrow.