Idaho doctors brace for impact on impending gender-affirming medication ban

As the new year approaches, Dr. Marvin Alviso is helping his patients plan for the future.

Some of his patients have moved on to doctors in other states, he said. The Boise doctor has helped patients stretch their prescriptions to last longer, for instance, by using extra doses of testosterone that normally go unused.

But starting in nine days, any Idaho doctor could face a felony for prescribing medications to minors who don’t feel at home in their own bodies.

Unless a court says otherwise, a new law banning puberty blockers, hormones and surgical interventions for Idaho youth seeking gender-affirming care will take effect Jan. 1.

Bracing for the ban, some Idaho doctors are exploring options for transgender and nonbinary Idaho youth to continue receiving treatment – by providing gender-affirming care that’s still allowed in Idaho and by referring patients to doctors in states where medications for youths aren’t criminalized. Opponents of the law hope that a court will stop the ban before it starts.

“I keep using the term ‘creative,’ because that’s what we’re doing,” Alviso told the Idaho Capital Sun in an interview about plans to continue providing health care. “This shouldn’t be how to provide care to kids, for care backed by science. Unfortunately, our lawmakers think otherwise.”

Idaho’s 2023 legislation changed landscape

In April, Idaho Gov. Brad Little signed House Bill 71, which will prevent transgender youth from accessing puberty blockers, hormones and surgeries in the state. Surgeries were already not happening on minors in Idaho, the Idaho Capital Sun previously reported. The law makes providing those medical treatments to minors a felony punishable by up to 10 years in prison.

Idaho is one of 22 states that passed a law or policy banning gender-affirming care for minors, according to the Human Rights Campaign, a national LGBTQ+ rights advocacy group.

Gender-affirming care is health care that is designed to affirm a person’s gender identity, the World Health Organization says. That includes social, psychological, behavioral or medical interventions, such as hormonal treatment or surgery. People who seek gender-affirming care are often experiencing gender dysphoria, or distress that stems from when a person’s gender identity does not match the sex assigned to them at birth, according to the Association of American Medical Colleges.

U.S. health care professionals, including Idaho doctors, saw this kind of legislation coming. In 2021, the American Medical Association urged the National Governors Association to oppose state legislation that prohibits gender-affirming care.

“It is imperative that transgender minors be given the opportunity to explore their gender identity under the safe and supportive care of a physician,” the association said. “This is a dangerous intrusion into the practice of medicine and we strongly urge the NGA and its member governors to oppose these troubling bills.”

Despite pleas from medical associations, LGBTQ+ advocacy groups, civil rights groups and transgender youth, Idaho lawmakers passed House Bill 71 with a 58-12 vote in the Idaho House of Representatives and a 22-12 vote in the Idaho Senate.

A federal judge overseeing a lawsuit brought by families of transgender Idaho youth has not indicated whether he’d halt the law. Health care professionals across Idaho are exploring alternatives to support young patients experiencing gender dysphoria, while adapting to the changes imposed by the law.

Doctors: Ban wouldn’t stop all gender-affirming care

A few years ago, a patient saw Boise pediatrician Dr. Jessie Duvall for the first time. They were depressed, had already attempted suicide and didn’t feel like their body matched who they were, Duvall said.

“They were just getting crushed by the world around them,” Duvall said.

But over the next year and a half, as they sought gender-affirming care and eventually started receiving hormone treatments at age 17, “you could see them get lighter and lighter,” Duvall said. Duvall doesn’t prescribe medications for gender-affirming care, but refers patients to local providers for medications.

If that teenager didn’t have hope that their body could match their identity, Duvall worries they might have attempted suicide again – and completed it.

“When we take away that option, we’re choosing for families and kids to put them into potential depression and at risk for suicide,” she said. “We’re taking away their right to live the life that they want to live, and the life their families want them to live.”

The bill would outlaw gender-affirming medications in Idaho, which is a critical component of gender-affirming care, Duvall said. But not all of it. Doctors can still help patients by, for instance, helping them access speech therapy, hair removal, breast binding and genital tucking, she said.

Rep. Bruce Skaug, R-Nampa, who sponsored the bill, said Thursday he hadn’t heard about how doctors planned to implement the ban. Plans that doctors shared with the Idaho Capital Sun, Skaug said, seemed legal. But, Skaug thinks gender-affirming care should really be called “gender denial,” he said, likening the care to lobotomies.

“Over time, these doctors are going to be seen like old doctors that did lobotomies,” he said. “It’s a fad, and it’s hurting people.”

‘My goal is to provide a safe space’

Like Duvall, Dr. Jessica Rolynn, a family medicine doctor based in Pocatello, told the Sun that she will not stop helping Idaho’s transgender youth.

Gender-affirming care is not just hormones, she said in a phone interview. It also includes supporting gender-affirming pronouns, clothing, hairstyles and providing safe spaces for her patients to explore their identity.

“My goal is to provide a safe space for people to explore who they are, and for them to get good health care in that process,” she said. “I want them to continue getting preventative care, cancer screenings, and flu shots, and I want them to feel that they have a space to come and tell me what is going on in their lives so that I can provide guidance for whatever kind of medicine they need.”

Rolynn said she advocated against House Bill 71’s passage. As an LGBTQ+ provider, she said providing gender-affirming care to youth is a standard of care for those experiencing gender dysphoria, meaning it is generally accepted by health care professionals.

She compared providing gender-affirming care to a patient to “seeing a flower bloom.”

“It’s really beautiful watching a person come into their own and seeing them discover who they are when they have gender-affirming services available,” she said.

But with the law’s start date looming, Rolynn said she is now focused on providing community outreach to help families understand gender dysphoria. She’s directing patients to a clothing closet at her clinic, monthly trans-affirming group meetups and counseling services.

While she would not be able to prescribe hormone medication and puberty blockers to young transgender patients, she said alternatives such as period suppression and acne treatment can be beneficial to address gender dysphoria.

“I’m trying so hard to let my patients know that I’m there for them, and I care about them,” she said. “And just because they don’t have access to hormone therapy under the age of 18 doesn’t mean that they don’t have access to good quality care.”

Idaho doctors to refer patients out-of-state

Dr. Henry Thompson, the medical director at St. Luke’s Children’s Hospital, told the Sun in an interview that House Bill 71 “dramatically changes” its program for youth with gender dysphoria, which accounts for about 200 of the hospital’s patients.

The health system hasn’t had to refer its patients to other states yet, Thompson said, but it would be legal.

The natural places to go for care out of state would be in Seattle, Portland, California or Colorado, he said – all hours away for Idaho patients.

Now more than ever, Thompson said, doctors are going to try to meet the anxiety, depression and mental health needs for young patients experiencing gender dysphoria.

“We can do a lot of things to make sure they’re heard, but we cannot provide the care that’s indicated in our state law,” Thompson told the Sun. “And it’s the same issue in the abortion arena. There’s no one that wants to go to prison for doing your job and doing the right thing.”

Thompson said he and his staff plan to keep supporting transgender youths and their families.

“We’re here to listen, we can help in some ways, and we can help you navigate this journey,” he said, addressing transgender youths in Idaho. “They aren’t alone, and they are valued as part of our community.”

Dr. Anna Chase, a family medicine doctor at Kootenai Health in Coeur d’Alene, said she also plans to refer patients to out-of-state providers.

In North Idaho, the closest place to access gender-affirming medication is Spokane, Chase said.

Kootenai Health does not have youth patients receiving gender-affirming medication, because months ago, most youth patients switched to providers in Washington in preparation for the new law, Chase told the Idaho Capital Sun. Kootenai Health has connections at the Oregon Health and Sciences University, which offers a transgender health program in Portland, parts of rural Oregon and via telehealth, Chase said.

Without providing gender-affirming medication, Chase said she can validate a patient’s identity and stress that “comes with living in Idaho.” Some steps Chase has taken in her practice include providing welcoming signs and language to her patients, she said.

Chase said that she feels bad that she can no longer provide hormone medication or puberty blockers to youth patients.

“Everybody who’s a physician has taken something called the Hippocratic Oath, which means do no harm,” she said. “You want to do the best for your patients, and this care has been validated and supported by major medical societies. It’s hard when you feel like you can’t do your job and you can’t do your best for your patients.”

Families of Idaho trans youths challenge House Bill 71

In May, the families of two transgender teens who receive gender-affirming care sued Idaho in federal court, alleging House Bill 71 violates the right to equal protection and undermines parental rights. The families are using surnames Poe and Doe to protect their identities.

It is awaiting a decision from federal Judge B. Lynn Winmill on their motion for a preliminary injunction, which would block the law from going into effect until the lawsuit is settled.

Skaug said he’s hopeful that the ban will be upheld in court. He said he is working on new legislation to ban public funds from supporting “sex changes.”

“Many of us worked very hard to make this bill so it would withstand constitutional muster in some of our liberal courts,” Skaug said. “… We may have to go all the way to the Supreme Court, but I think this bill will withstand judicial scrutiny.”

Ritchie Eppink, an attorney at Wrest Collective representing the plaintiffs, told the Sun the families involved have been exploring their options for months, including traveling out of state or moving.

But those options are not feasible for all Idaho families, he said.

“We are expecting the judge to issue a decision any day now,” he said. “We know he’s well aware that the law will take effect on Jan. 1 and is trying to get a decision made as soon as he can before that deadline.”

Eppink said the well-being and health care of the families and the youths involved in the lawsuit depend on the decision about House Bill 71.

“The next step in the case if the law isn’t enjoined will have to be informed by the Court’s reasoning, but you can be sure that we will continue to fight this unconstitutional ban and try to ensure access to medically necessary health care for Idaho youth,” Eppink said.

Boise doctors talk challenges

Alviso sees about 400 patients. About 20 are minors receiving gender-affirming care, he said.

The minors Alviso treats, he said, know the medications, their side effects and that they’ll have to go through extra steps to get the care they need.

“They know that we have to fight for this,” he said.

Although Alviso would not be able to prescribe medications under the pending law, he says his doors are still open to provide gender-affirming care – including referrals to mental health providers or referrals to medical providers out of state.

But he’s still frustrated that he can’t provide medicine backed by major medical institutions. And he’s not alone.

“It’s been incredibly challenging that medical expertise is not actually valued, down the block,” Thompson said. “It makes it challenging for providers to do their jobs. And honestly, I think it’s going to get worse before it gets better.”