CHICAGO — The American Medical Association (AMA) today urged governors to oppose state legislation that would prohibit medically necessary gender transition-related care for minor patients, calling such efforts “a dangerous intrusion into the practice of medicine.” In a letter to the National Governors Association (NGA), the AMA cited evidence that trans and non-binary gender identities are normal variations of human identity and expression, and that forgoing gender-affirming care can have tragic health consequences, both mental and physical.

“Decisions about medical care belong within the sanctity of the patient-physician relationship,” the AMA wrote in its letter. “As with all medical interventions, physicians are guided by their ethical duty to act in the best interest of their patients and must tailor recommendations about specific interventions and the timing of those interventions to each patient’s unique circumstances. Such decisions must be sensitive to the child’s clinical situation, nurture the child’s short and long-term development, and balance the need to preserve the child’s opportunity to make important life choices autonomously in the future. We believe it is inappropriate and harmful for any state to legislatively dictate that certain transition-related services are never appropriate and limit the range of options physicians and families may consider when making decisions for pediatric patients.”

The complete text of the letter is below, and a pdf copy can be downloaded by clicking here.

Dear Mr. McBride:

On behalf of the American Medical Association (AMA) and our physician and medical student members, I write to urge the National Governors Association (NGA) and its member governors to oppose state legislation that would prohibit the provision of medically necessary gender transition-related care to minor patients. We believe this legislation represents a dangerous governmental intrusion into the practice of medicine and will be detrimental to the health of transgender children across the country.

Empirical evidence has demonstrated that trans and non-binary gender identities are normal variations of human identity and expression. For gender diverse individuals, standards of care and accepted medically necessary services that affirm gender or treat gender dysphoria may include mental health counseling, non-medical social transition, gender-affirming hormone therapy, and/or gender-affirming surgeries. Clinical guidelines established by professional medical organizations for the care of minors promote these supportive interventions based on the current evidence and that enable young people to explore and live the gender that they choose. Every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people.

Arkansas’ recently enacted SAFE Act and similar bills pending in several other states would insert the government into clinical decision-making and force physicians to disregard clinical guidelines. Decisions about medical care belong within the sanctity of the patient-physician relationship. As with all medical interventions, physicians are guided by their ethical duty to act in the best interest of their patients and must tailor recommendations about specific interventions and the timing of those interventions to each patient’s unique circumstances. Such decisions must be sensitive to the child’s clinical situation, nurture the child’s short and long-term development, and balance the need to preserve the child’s opportunity to make important life choices autonomously in the future. We believe it is inappropriate and harmful for any state to legislatively dictate that certain transition-related services are never appropriate and limit the range of options physicians and families may consider when making decisions for pediatric patients.

In addition, evidence has demonstrated that forgoing gender-affirming care can have tragic consequences. Transgender individuals are up to three times more likely than the general population to report or be diagnosed with mental health disorders, with as many as 41.5 percent reporting at least one diagnosis of a mental health or substance use disorder.¹ The increased prevalence of these mental health conditions is widely thought to be a consequence of minority stress, the chronic stress from coping with societal stigma, and discrimination because of one’s gender identity and expression. Because of this stress, transgender minors also face a significantly heightened risk of suicide.

Transgender children, like all children, have the best chance to thrive when they are supported and can obtain the health care they need. Studies suggest that improved body satisfaction and self-esteem following the receipt of gender-affirming care is protective against poorer mental health and supports healthy relationships with parents and peers.² Studies also demonstrate dramatic reductions in suicide attempts, as well as decreased rates of depression and anxiety.³ Other studies show that a majority of patients report improved mental health and function after receipt of gender-affirming care. Medically supervised care can also reduce rates of harmful self-prescribed hormones, use of construction-grade silicone injections, and other interventions that have potential to cause adverse events.⁴

It is imperative that transgender minors be given the opportunity to explore their gender identity under the safe and supportive care of a physician. Arkansas’s law and others like it would forestall that opportunity. 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.

We thank you for the opportunity to express our views on this important issue.

Sincerely,

James L. Madara, MD

CEO and EVP, American Medical Association

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¹ Sari Reisner, et al., Psychiatric Diagnoses and Comorbidities in a Diverse, Multicity Cohort of Young Transgender Women: Baseline Findings from Project LifeSkills, 170 J. Am. Med. Ass’n Pediatrics 5, 481–86 (May 2016).

² Ashli Owen-Smith, et al., Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals, 15 J Sexual Med 4, 591-600 (Apr. 2018); Michelle Marie Johns, et al., Protective Factors Among Transgender and Gender Variant Youth: A Systematic Review by Socioecological Level, 39 J Primary Prevention 3, 263-301 (Jun. 2018).

³ M. Hassan Murad, et al., Hormonal Therapy and Sex Reassignment: A Systematic Review and Meta-Analysis of Quality of Life and Psychosocial Outcomes, 72 Clinical Endocrinology 2, 214-331 (Feb. 2010); Yolanda Smith, et al., Sex Reassignment: Outcomes and Predictors of Treatment for Adult and Adolescent Transsexuals, 35 Psychological Med. 1, 89-99 (Jan. 2005).

⁴ Jessica Xavier, Admin. HIV and AIDS, D.C. Gov’t, The Washington Transgender Needs Assessment Survey (2000); Wendy Bostwick & Gretchen Kenagy, Health and Social Service Needs of Transgendered People in Chicago, 8 Int’l J Transgenderism 2-3, 57-66 (Oct. 2008); Cathy Reback, et al., Los Angeles Transgender Health Study: Community Report (2001).