What is gender-affirming care? Transgender healthcare in Spokane comes into focus as Idaho ban faces lawsuit

A few years ago, Demitri Van Liew would be “physically sick” in public without wearing a tight-fitting binder or specialized tape flattening his chest.

He worried people could tell he was a transgender man. But even more, his chest felt alien – like it wasn’t really his.

“Having dysphoria is having this disconnect between your mind and your body. It makes you want to crumble in and feel disgusted with yourself,” Van Liew explained.

Gender dysphoria is an experience many transgender people share – a kind of distress when a person’s external body does not match the gender they identify with on the inside. Experiencing gender dysphoria can cause debilitating depression, and it is the reason many individuals seek gender-affirming medical care to align their body with their internal experience.

For Van Liew, that has meant chest surgery and hormone therapy replacing the estrogen his body naturally produces with testosterone.

“I haven’t really stopped feeling the joy of being recognized as a man and people not even having to think about it,” he said.

Van Liew began his medical transition at 19 but knew himself to be transgender early into his adolescence.

Trans teens have received intense scrutiny in recent years as states have sought to restrict minors’ access to gender-affirming care.

Those younger than 18 can receive gender-affirming care in Washington, but that may not be the case soon in Idaho. In April Idaho’s governor signed a ban set to go into effect this month. Implementation of the law was temporarily halted by a federal judge just before the new year as a lawsuit works through the court.

What is gender-affirming care?

Gender-affirming care includes a number of interventions supporting and affirming an individual’s gender when it is different from the sex they were assigned at birth. Many of these interventions are medical but can also involve psychological counseling and behavioral changes.

“My job is to really try to help people live their true selves and help them align various aspects of their lives – the biological and the emotional,” said MultiCare Rockwood primary care physician Dr. Rachel Safran, who treats transgender patients in Spokane.

The most common medical intervention for transgender adults is hormone replacement therapy. This also is a common treatment in cisgender, or nontransgender, patients who have a deficit of sex hormones for whatever reason. In the context of transgender care, patients have their hormones replaced with those of the opposite natal sex.

Under this treatment, a transfeminine individual takes estrogen and another drug blocking her body’s natural production of testosterone. Among other effects, she will experience breast growth, softening of skin, redistribution of fat across the body to the hips and breasts, and a decrease of testicular volume.

In contrast, transmasculine individuals taking testosterone experience facial and body hair growth, increased muscle mass, decreased fat mass, deepening of the voice, fat redistribution and clitoral growth.

Patients will typically see these changes’ full effects after two to three years and must continue hormone therapy to maintain them.

Other forms of gender-affirming care include surgery and puberty blockers, but they are much less common.

What is it like being a trans teen?

Growing up in Spokane, it was difficult for Van Liew, 24, to be “taken seriously” as a transgender guy by adults. Without access to gender-affirming care, he was unable to “pass” as male, causing him a lot of dysphoria.

“I had to correct everybody. Nobody treated me as male, especially after I entered the workforce. I was dressing masculinely. I was doing everything I could,” he said.

Van Liew’s parents did not accept his gender as a teenager, and he was unable to access gender-affirming care even though it was legal for minors to do so in Washington. Upon beginning testosterone treatment at 19, he passed quickly as male, and his life drastically improved.

“After four months of testosterone, everyone could immediately tell I was a guy. My voice dropped a little in the first few months and the shape of my face changed,” he said.

Over the course of an hour-and-a-half appointment, providers at Planned Parenthood in Spokane explained all the changes he could expect from beginning testosterone therapy and gave him a packet with that information. Upon reviewing the packet for a week, Van Liew returned for a second appointment and began weekly testosterone injections.

After more than a year on hormone therapy, Van Liew sought chest surgery to relieve the dysphoria he felt about that part of his body. He is happy with the results over two years later.

“Since top surgery, I have been on an endless high. My confidence has skyrocketed, and my dysphoria has improved phenomenally,” he said.

What is Idaho’s ban?

Under Idaho’s Child Protection Act, medical practitioners cannot “alter the appearance” of a child’s sex or “affirm the child’s perception” of their sex or gender if it differs from the sex they were assigned at birth.

The law specifically cites surgeries that “sterilize or mutilate genitalia,” puberty-blocking medication and hormone therapy for the purpose of transition. The statute specifically exempts any of these same treatments used to affirm the gender of cisgender children or to change the birth sex of any children born with intersex variations. Intersex people have internal or external reproductive anatomies that don’t neatly fit into the binary sex assignments of male and female.

If enacted into law, medical providers violating these provisions would be at risk of felony charges and years of imprisonment.

“These experimental, irreversible, and medically unnecessary pharmaceutical and surgical interventions violate the Hippocratic oath, taken by physicians for millennia, to ‘do no harm,’ ” the text of the law states.

In a February 2023 hearing on the then-proposed legislation, bill sponsor and Republican state Rep. Bruce Skaug, of Nampa, likened the use of gender-affirming care to eugenics campaigns in the early 20th century, which advocated removing less desirable traits from the population through forcible sterilization.

“There’s a sad history by the way – in America and other parts of the world sterilizations were at one time used to improve the race, so to speak. To eliminate procreation of the feeble-minded or those of lower IQ ..,” Skaug said. “We do not allow minors to get tattoos, smoke cigarettes, drink alcohol, sign legal documents. Why would we allow them to make decisions to cut away healthy bodily organs and to start down the road to chemical castration at age 12?”

The law was set to be enacted on Jan. 1, but a federal judge temporarily blocked it.

Medical guidance on gender-affirming care for minors

Gender-affirming care for adults and minors is supported by all major medical associations, including the American Medical Association and the American Academy of Pediatrics. Medical providers of gender-affirming care typically follow guidelines created by the World Professional Association for Transgender Health, or WPATH.

In the organization’s latest set of guidelines released in 2022, prepubescent children are “ineligible for medical intervention.”

According to the guidelines, these children should receive psychotherapy and may socially transition, or be affirmed in their gender expression without medical intervention.

Any medical step is taken with the permission of a parent or guardian, unless the child is in foster care or parental involvement would be “impossible, inappropriate, or harmful.”

“For minors, the legal guardian is integral to the informed consent process: if a treatment is to be given, the legal guardian … provides the informed consent to do so,” the guidelines read.

Typically at 12 years old or at the very onset of puberty, puberty suppressants can be considered. These blockers are fully reversible and pause puberty development to give the transgender youth more time and maturity to make a more permanent decision. Puberty blockers also are used frequently for cisgender children whose puberty begins too early.

Hormone replacement therapy is typically considered beginning at age 16 and when the adolescent has experienced gender incongruence over a “sustained” period. Those under 18 years of age are typically ineligible for any gender-affirming surgery.

Idaho sued over transgender law

Two transgender adolescents and their respective parents sued the state following passage of the bill. In both cases, the children and parents adopted pseudonyms for their protection.

The two transgender girls experienced depression, suicidal ideation and self-harm at the onset of puberty. To relieve their distress, they told their parents.

“My body started changing as I entered puberty. It became increasingly devastating to me, and my mental health began to deteriorate …” plaintiff Jane Doe wrote in a court filing. “There were times that I simply just did not want to exist because the physical changes to my body were trapping me in an existence that was not me and caused me so much pain, on a constant basis.”

Both plaintiffs began puberty blockers to stop their natal secondary sex characteristics mid-puberty and then switched from blockers to estrogen therapy, which simulated a female puberty. Both girls described how many of their depressive symptoms subsided.

“Gender-affirming medical care saved my life. When I think back to that time, it makes me sad. I know it really scared my parents. It scared me too. I did not want to die, I just wanted to be myself, my true self. I am so glad that I told my parents about what I was struggling with. I wish I had told them sooner,” plaintiff Pam Poe wrote in a court filing.

Both families plan to move out of Idaho if the ban on gender-affirming care to minors, House Bill 71, is enacted.

“I am really scared. My parents and siblings are scared, and the others who love and care about me are scared, too. The anxiety from H.B. 71 and the possibility of my healthcare being taken away and having to go back to life as it was before I began receiving gender-affirming medical care is very stressful and harmful to my mental health,” Doe wrote.

Judge B. Lynn Winmill put in place a preliminary injunction to stop enforcement of the law pending his final ruling in the case. Though the injunction is not definitive, it can only be put in place because the law’s opponents have a “strong likelihood of success.”

Winmill ruled the parents in this case “enjoy a fundamental right to seek a specific form of medical treatment for their children.” He also called medical interventions like puberty blockers, hormone therapy and surgery “safe, effective and medically necessary for some adolescents.”

In a statement following the judge’s ruling, Idaho Attorney General Raul Labrador said it is “hard to overstate the magnitude of the court’s error.”

“The federal judiciary once endorsed the eugenics movement and forced sterilization of intellectually disabled people. Similarly, Judge Winmill’s ruling places children at risk of irreversible harm. History will not look kindly at this decision. We are taking immediate action to appeal this decision and are confident that correction will come. I will never stop fighting for and protecting our most vulnerable children,” he said.

How do you receive gender-affirming care?

Safran typically takes several months of “getting to know their gender journey” before prescribing medication unless the individual already has started hormone replacement therapy – called HRT – elsewhere.

“I do not offer immediate prescriptions,” she said. “For me, I want to make sure that it’s the right choice and the safest choice for people but would take a few visits of getting to know someone to make sure that it’s the right thing.”

Some other providers in Spokane do provide an HRT prescription in their patient’s first visit in some cases. According to Tracy Worley, Planned Parenthood’s associate medical director of greater Washington and North Idaho, a transgender patient at one of their clinics can start medications after their first appointment unless other outside support is needed for the patient or there is an allergic reaction to a treatment.

“During a patient’s first appointment, we review health history, social history, goals and expectations of the patient, review medications offered for care, informed consent, timeline of expected changes. We want to get to know the patient and understand if they have support or need referral for outside resources,” Worley said.

World Professional Association of Transgender Health guidelines recommend providers focus on obtaining informed consent from any transgender patient before beginning hormone therapy by insuring they understand the effects of the treatment. According to WPATH, some individuals will have the capacity to consent in an initial assessment, while others need a longer process to understand the information and make an informed decision.

“Informed consent models of care prioritize the adult as the decision maker with the healthcare provider acting as an advisor,” the standards of care state.

According to Safran, it is inaccurate to suggest providers like her will rapidly prescribe HRT “without any thought or deliberation.”

“That’s not true. As health care providers, we’re very careful and cautious to make sure it’s the right thing for each individual person,” she said.

This deliberative process becomes more pronounced for patients who are adolescents or children.

WPATH guidelines direct providers to only recommend surgery when gender incongruence “is marked and sustained,” the patient has been treated with HRT for a minimum of six months and they have received a note from a therapist.

Another concern by opponents of gender-affirming care is that hormone therapy and some surgeries could affect an individual’s fertility. Although the issue is understudied, transgender people on HRT can regain their fertility in many cases.

According to WPATH, transgender women can regain fertility by discontinuing HRT for three months, although it can often take longer. Ovarian function among transgender men who have stopped hormone therapy showed no difference with cisgender women, according to data cited by WPATH.

Fertility function can also continue while use of hormone therapy does, so HRT is not an effective method of birth control.

There is little to no data at this time on the fertility of transgender individuals who began their medical transition as adolescents or children.

Where can transgender people receive

gender-affirming care?

It often can be difficult for transgender people seeking gender-related care for the first time to know where to go. Many doctors and other health care professionals receive little or no training in how to provide gender-affirming care to transgender people. As a result, there are often few providers in a given community who will prescribe hormone therapy for transgender patients.

WPATH urges primary care physicians to provide gender-affirming care to transgender patients without the need to refer them to a specialist.

“If providers are competent to deliver similar care for cisgender patients, they should develop competency in caring for (transgender) patients,” the guidance reads.

Safran is one of a “small number” of MultiCare Rockwood physicians who provide gender-affirming care and receive internal referrals of transgender patients from other Rockwood clinicians. In her experience, it is important for transgender patients to receive holistic treatment from the same provider if possible.

“For my transgender patients, they want one doctor who takes care of all of their conditions. And so, I really learned through my patients about the importance of gender-affirming care,” she said.

Other medical providers in Spokane that provide gender-affirming care include Planned Parenthood, Chas Health and Providence.

Chas Health is one of the only providers in the area that appears open to hormone therapy and blockers to minors as well as adults.

“CHAS Health providers work closely with all established patients, and their parents when minors, to determine the best course of care to meet their healthcare needs,” the organization said in a statement.

Kootenai Health in North Idaho provides gender-affirming care to adults and has provided such care to children and adolescents in the past.

“Kootenai Clinic remains committed to providing quality, medically appropriate care to all patients. There is a team of medical professionals at Kootenai Clinic that can help patients seeking gender-affirming care navigate their health questions. We will continue to care for our patients while remaining in alignment with both our mission and state law,” Kootenai Health spokesperson Caiti Bobbit said in a statement.

Kootenai Health physician Anna Chase was interviewed by the Idaho Capital Sun last month about transferring her underage transgender patients to clinics in Spokane and elsewhere in anticipation of Idaho’s new law.

Can Providence provide gender-affirming care?

Providence, which is the largest health care provider in Spokane, provides gender-affirming care as part of a clinic focusing on LGBTQ+ patients, including transgender people, led by Dr. Sarah Wilhelm.

“Our mission is to provide quality care for everyone, especially those who are vulnerable or marginalized. So we pride ourselves in taking care of all individuals,” said Providence Chief Medical Officer Rebecca Mallo.

As a Catholic institution, Providence Sacred Heart and their other facilities in Spokane follow the Ethical and Religious Directives for Catholic Health Care Services, a set of standards concerning Catholic religious teaching that informs and guides church health care providers. Drafted by the United States Conference of Catholic Bishops, the edition of the Ethical and Religious Directives for Catholic Health Care Services do not directly address gender-affirming care for transgender patients.

While treatment of transgender patients varies across Catholic health care institutions, Providence in Spokane provides hormone replacement therapy to transgender adults but not any gender-affirming surgery. Providence will not provide hormone therapy, hormone blockers or surgery to any transgender minor. Providence will refer patients elsewhere if they can’t address their needs.

Those policies could change soon.

Last year, the United States Conference of Catholic Bishops released a doctrinal note regarding transgender issues and has begun rewriting the directives to specifically address transgender care. While it is unclear what these revisions will entail, their doctrinal statement suggests Catholic health care institutions will be restricted from providing gender-affirming care.

“Catholic health care services must not perform interventions, whether surgical or chemical, that aim to transform the sexual characteristics of a human body into those of the opposite sex or take part in the development of such procedures,” the note reads.

According to the Bishops, these interventions are “not morally justified” and “do not respect the fundamental order of the human person as an intrinsic unity of body and soul.”

In a statement, Providence said they are “not a regional expert on gender-affirming procedures and treatments” but are “proud to offer the transgender community a respectful, welcoming place of healing.”

“Our shared Mission calls us to recognize the inherent human dignity of each individual, especially those who are vulnerable and marginalized. This includes members of the transgender community, who we know are subject to greater risk of suicide, homelessness, harassment, bullying and acts of violence. In line with state and federal laws – and more importantly, our Mission and values – we provide patients with the full range of care available at our facilities consistent with the interpretation of the Catholic Ethical and Religious Directives,” Providence said in a statement.