Columbus, Ohio—Gov. Mike DeWine’s proposal for additional regulations on trans treatment for Ohioans of all ages is causing conflict between health professionals and the state.
If adopted, these regulations would align with the individual laws prohibiting transgender minor care that was approved this month over DeWine’s veto.
Health professionals currently follow the standards established by the World Professional Association for Transgender Health for the best practices in transgender medicine. Sana Loue, a professor of bioethics at the Case Western Reserve University School of Medicine, argued that the new laws violate these standards and pose ethical challenges.
“I don’t think anyone would disagree with the regulations if they exactly mirrored the level of care that various organizations, including the Academy of Pediatrics, recommended. However, that is not what is happening here.”
For instance, the new regulations might endanger patient privacy, forbid specialists from disclosing patient information, and restrict adults’ ability to choose their own health care.
Critics argue that the core issue is who should be in charge of setting the rules—the government or health professionals.
There are many procedures where doctors examine people and give their consent before performing procedures like transplants, plastic surgery, and gastrointestinal surgery. Additionally, many of the same procedures that are prohibited in trans care are also given to patients who identify as cisgender. However, none of these practices are governed by legislation.
The law itself is not too complicated. All gender-affirming care for minors is outlawed under HB 68, which will go into effect in April, and transgender women and girls are not allowed to participate in youth activities.
However, the independent rules that Gov. Mike DeWine may take things a step further following his veto of the expenses, which was overridden this year.
DeWine first proposed using the laws as a way of bridging the gap between the various parties involved. However, DeWine’s ideas impose more restrictions that impact adults as well as children.
When asked on Wednesday about criticism of his proposed rules, DeWine responded that they are not yet final and that he was “impressed” by the volume of public comments made about them.
The state rule-making process is currently going through the proposed principles.
“You’re going to see some edits of this proposal that we put forward quite soon,” DeWine said.
The governor chose not to specify what those adjustments would entail. However, he added, “aspirationally,” we want to ensure that great medical training is adhered to. And it is abundantly clear that counseling must be a part of good clinical practice from the beginning.
Requirements may mandate that doctors treating trans patients report all of the procedures they perform to the state under the new laws and DeWine’s individual plan.
They mandate that all people must have a care program that has been reviewed by an expert in medical ethics, as well as the existence of contracts between all gender-affirming care providers and psychologists and endocrinologists. Adolescents are not allowed to request a referral for gender reassignment surgery or even to learn more about it, and anyone under the age of 21 is not permitted to receive care without receiving an in-depth emotional assessment and treatment for at least six months.
This has had many clinical and advocacy companies in uproar from the beginning. The ACLU claimed that the restrictions only constituted a “de facto restriction on care for transgender children and adults” and that they might be used to put obstacles in the way of people seeking gender-affirming treatment.
Loue concurs. She claims that not only is there no such thing as a skilled ethicist, but that there are also very few bioethicists working in the medical field. Finding one could be extremely difficult, depending on where you live, in addition to the fact that no insurance program is likely to cover the cost.
She also objects to the data collection because, even when names aren’t used, information like the patient’s age, race, state of residence, and treatments tend to make transgender persons easily identifiable when you’re talking about a small group of people.
According to Loue, there is sort of a rule in epidemiological studies that states that you shouldn’t include those people in the data if the trial is too small because it will be too easy to identify them. That is a serious social issue, especially for people living in rural areas.
And mandating that people under the age of 21 undergo six weeks of counseling and a mental health assessment? “Why is the age of 21 the cutoff when someone is 18 and no longer a minor?” Loue asked. That raises a problem because you’re now claiming that someone is incapable of making independent decisions.
In the best-case scenario, Loue claims that patients of legal age are prevented from receiving care due to the regulations’ financial and logistical responsibilities. However, they go even further than that, she claims, by limiting minors’ access to fundamental information about future care.
According to Loue, the clause that forbids even implicit information referral is extremely difficult because it prevents people from actually getting information to determine whether they
might need it in the future. “That is morally difficult because a person is entitled to know the details of the process.”
Loue adds that many of the methods that are forbidden for helping trans patients are already being used in cisgender patients without any limitations or reporting requirements.
For instance, young menstruation, a condition that starts in early childhood and affects girls, frequently involves the use of puberty blockers. Men and women with lower estrogen levels are given testosterone and estrogen.
“We regularly use hormones, and no politician has ever told me that I need a comprehensive acceptance,” said Andrew Davis, a University of Chicago professor of internal medicine and the creator of many experiments on trans care.
The restrictions are often referred to as “guardrails” by Dan Tierney of the governor’s office, implying that it is necessary to shield transgender patients from potentially damaging treatments.
However, Andrew Fisher, an OBGYN who oversees the Transgender Clinic for Affirmation and Reproductive Equity at the University of Chicago, asserts that the health risks to transgender patients aren’t any higher than those of their cisgender counterparts.
“The trans and gender-diverse population is significantly less at risk from all of these risks,” Fisher said. And compared to cis-gender individuals, we are keeping a little closer eye on these patients and their hormone levels.
The safety and effectiveness of hormone therapy studies, according to those who oppose gender-affirming care, are not demanding enough, and many transgender people who undergo surgery often regret their choice. However, neither Fisher nor Davis assert that these assertions are supported by science.
According to a recent JAMA report, post-surgical regret among transgender people is significantly lower (1%) than after other typical surgeries (14%).
Furthermore, according to Carl Streed, president of the U.S. Professional Association for Transgender Health, the American arm of WPATH, randomized, double-blinded clinical trials examining the effects of hormone therapy on gender dysphoria are not only impractical (one cannot administer hormones in a blinded manner), but also unethical in that they would necessitate denying care.
He claimed that there are numerous different instances where random, blinded clinical trials are not the norm and that making such a claim would be inconsistent with how clinical research is carried out.
Streed remarked, “We’ve been using antibiotics to treat sore throat for years without actually having a study demonstrating that it should be done that way, but that’s what we do because it works.”
“The state needs to mouth out like they have in almost all of our care and leave it to the real professionals providing the care and the companies that give them advice and management around this,” he added. “That is the purpose of health boards. That is the purpose of health cultures. That is the purpose of the education that we have received over many years.”
Although they have not yet issued an official declaration on the governor’s more regulations, a coalition of health societies, including the Ohio State Medical Association, the American Academy of Pediatrics, and the American College of Obstetrics and Gynecology, have previously written letters opposing HB68. These letters quite clearly state their position:
In a letter dated December 5 addressed to Senate President Matt Huffman, they stated that “we believe that parents and people should be able to get attention from trusted physicians or medical providers without congressional interference.”
The governor’s office disputes that the laws’ stated purpose is to limit treatment. Loue contends, nevertheless, that the rules are much more likely to be detrimental than beneficial.
Early intervention with gender-affirming hormones not only enhances mental health but also significantly lowers rates of suicide and self-harm, according to Loue. It also lessens the possibility that children will eventually need surgery for things like breast enlargement or reduction or the removal of an Adam’s apple that is protruding.
Loue remarked, “There’s truly a lack of recognition of what occurs below in medicine.”
Jeremy Pelzer and Laura Hancock, two Statehouse writers, contributed to this article on cleveland.com. Gretchen Cuda Kroen provides health care for cleveland.com.
