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Florida Restricts Doctors From Providing Gender Treatments to Minors

The state’s medical board, whose members are appointed by the governor, has barred doctors from prescribing gender care to new adolescent patients.

A rally in support of transgender young people outside Orlando City Hall in June 2021.Credit...Lizzie Heintz/Orlando Sentinel/Sipa USA/Alamy Live News

Azeen Ghorayshi, who reports on science and gender, went to Orlando last week to watch the state medical board’s contentious hearing on transgender health care.

Florida has effectively banned medications and surgery for new adolescent patients seeking gender transitions after an unprecedented vote by the state’s medical board.

The move makes Florida one of several states to restrict what’s known as gender-affirming care for adolescents, but the first to do so through the actions of its Board of Medicine, whose 14 members were appointed by Gov. Ron DeSantis. The strategy circumvented the Republican-controlled State Legislature, which had twice declined to take up a bill aiming to restrict such treatment.

The board voted 6-3 (with five others not present) on Friday to adopt a new standard of care that forbids doctors to prescribe puberty blockers and hormones, or perform surgeries, until transgender patients are 18. Exceptions will be allowed for children who are already receiving the treatments.

The Florida Board of Osteopathic Medicine also voted to restrict care for new patients on Friday, but allowed an exception for children enrolled in clinical studies. Doctors who flout the rules risk losing their medical licenses.

“The chief point of agreement among all of the experts — and I must emphasize this — is that there is a pressing need for additional, high-quality clinical research,” Dr. David A. Diamond, a radiation oncologist and the chair of the board, said on Friday.

The decision followed months of heated discussion, including a tense and at times bitterly divided public meeting in Orlando last week featuring testimony from doctors, parents of transgender children and adults who have come to regret their transitions.

And it comes four days before the conclusion of the governor’s race in the state and as conservatives have adopted gender-related medical care for adolescents as a key issue on the national political stage. Mr. DeSantis, a Republican widely believed to have presidential ambitions, declared in a recent debate that such treatments would not be allowed in Florida. Before the medical board decided to craft the new standard, members received personal calls from the state’s surgeon general, Dr. Joseph Ladapo, urging them to do so.

Earlier this year, Florida became one of at least nine states to bar Medicaid coverage of gender-affirming care, affecting thousands of low-income adults and children.

Such treatments for adolescents typically include puberty blockers, which stall development, often followed by testosterone or estrogen to bring about secondary sex characteristics that better align transgender adolescents’ bodies with their experience of gender. A small but growing number of adolescent patients pursue surgeries, most often to remove their breasts. All treatments require parental consent and approval from physicians.

Major medical groups in the United States, including the American Academy of Pediatrics, have condemned state bans and insurance restrictions of such care as dangerous political intrusions into standard medical practice. Transgender adolescents struggle with high rates of depression and anxiety, and small studies suggest that such medical interventions can help ameliorate body-related distress and improve the adolescents’ well-being.

But the rapidly rising number of adolescents seeking such treatments and a lack of data on their long-term outcomes has also raised concerns among some clinicians worldwide. At the public meeting last week, board members made frequent references to changes in Europe, where some countries have recently limited which adolescents can receive puberty blockers and hormones.

The United States, in contrast, has taken an all-or-nothing approach. Arkansas and Alabama have passed laws making it illegal for doctors to provide any gender-related care to minors. In Texas, Gov. Greg Abbott ordered the state’s child welfare agency to investigate parents of transgender children on suspicion of child abuse. (These actions are facing court challenges from civil rights groups.)

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Mr. DeSantis nominated Dr. Joseph Ladapo as surgeon general in September 2021.Credit...Chris O'Meara/Associated Press

Florida has taken a different path, instituting a ban through its medical board, which is overseen by the state’s Department of Health. The board is primarily responsible for licensing and disciplining doctors, but it sometimes also crafts health care guidelines.

Eight members of Florida’s board have donated a combined total of nearly $100,000 to Mr. DeSantis’s campaigns over the past decade. Four members have each donated more than $15,000.

The board’s vote on Friday raises questions about the role of a politically appointed body in controlling complex and highly personal medical decisions, particularly in an election year. The board typically focuses its actions on grave threats to public health, such as opioid abuse or procedures like so-called Brazilian butt lifts that have resulted in many patient deaths in Florida. In August, a lawyer for the health department acknowledged that the state had not received any patient complaints about gender-affirming care.

“I feel very strongly that this is a misuse of their power,” said Dr. Meredithe McNamara, an adolescent medicine physician at Yale who treats transgender children and testified at the meeting.

Mr. DeSantis nominated Dr. Ladapo, a physician and clinical researcher then at the University of California, Los Angeles, as surgeon general in September 2021. Together, the two men have repeatedly taken scientific uncertainty — be it about coronavirus vaccines or about gender-affirming care in adolescents — and wielded it to justify aggressive policies out of the mainstream medical orthodoxy.

A Republican state lawmaker in Florida introduced legislation in 2021 and again this year that would have criminalized the performing of gender-affirming surgery on transgender adolescents and would have made it a first-degree misdemeanor to prescribe puberty blockers and hormones. In both years, the bill did not advance in the state’s House of Representatives.

In April, Dr. Ladapo sent a letter to physicians in Florida recommending against prescribing gender-affirming medications and surgeries for minors as well as facilitating social transitions, such as changes in hair styles or pronouns. The memo spurred a state investigation that prompted the loss of Medicaid coverage of gender-related treatments for patients of all ages.

In June, Dr. Ladapo asked the state’s medical board to consider a ban, arguing that evidence for gender-affirming care in adolescents was “extraordinarily weak” and that it came with a “high risk for long-term, irreversible harms.”

Two months later, on the evening before the board was scheduled to vote on whether to craft its own rule, Dr. Ladapo called board members to check in, an unusual move, according to one member who requested anonymity because he was concerned about his privacy. Typically, he said, the board would decide to investigate physicians after receiving complaints, not at the behest of the surgeon general. The next day, the board voted to draft a new standard of care.

The Department of Health, which Dr. Ladapo oversees, said that there was nothing inappropriate about the surgeon general reaching out to the board members.

“I am not sure why it is shocking for the surgeon general to communicate with members of any board, which are overseen by the Department of Health,” Weesam A. Khoury, the deputy chief of staff of the department, said in an email. She added that Dr. Ladapo had also recently contacted members of the state Board of Osteopathic Medicine to check on their safety after they had received death threats related to this issue.

But the push to ban the care did not sit well with some members of the medical board. Dr. Kevin Cairns, a spine specialist from Fort Lauderdale, stepped down in October as the vice chair of the board because he was disappointed by the medical board’s actions on this issue, according to two people familiar with his decision.

At the meeting last Friday, with an audience of roughly 200 people, the board heard testimony from doctors who treat transgender adolescents, as well as from two critics who do not specialize in such care.

Dr. Kristin Dayton, a pediatric endocrinologist and the head of the youth gender program at the University of Florida in Gainesville, spoke about her experience treating transgender adolescents. After two other clinics in Florida stopped accepting new patients this year, Dr. Dayton’s clinic, which sees about 300 patients, became the only option for children seeking care in the state.

“Our patients report reduced suicidal ideation and increased satisfaction with their lives after being given access to gender-affirming hormone therapy,” Dr. Dayton said.

But she urged the board to consider that not all patients received medical interventions. “There is no one-size-fits-all model for care,” Dr. Dayton said.

Arguing in favor of restrictions, Dr. Riittakerttu Kaltiala, a professor of adolescent psychiatry at Tampere University in Finland, testified about leading the youth gender program in that country since 2011.

The vast majority of her patients were assigned female at birth and began experiencing distress about their gender identity later in adolescence, she said. And many of her patients with co-occurring psychological issues were not helped by the treatments, she said. In 2020, Finland began limiting puberty blocking and hormonal treatments for minors, prescribing them only to adolescents with clear diagnoses of gender dysphoria and expanding the availability of talk therapy.

“This is really my sincere understanding: that the evidence is lousy,” Dr. Kaltiala told the board.

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Chloe Cole spoke at a news conference on Capitol Hill in September.Credit...Drew Angerer/Getty Images

Following the testimony last week, the board opened the meeting to public comment, inviting nine people who had reversed their gender transitions, or detransitioned, to speak first. Many said their transitions had occurred during periods of intense psychological distress with little scrutiny from physicians.

“I actually developed more psychiatric issues the further I went into transition,” said Chloe Cole, 18, who speaks frequently to the news media and had testified in favor of the state’s Medicaid ban. She began testosterone treatment at age 13 and had surgery to remove her breasts at 15. A year later, she said, she realized that her transition was a mistake and stopped taking hormones.

Several parents spoke about how their children’s lives had been greatly improved with gender-related medical support. One mother, Hope McClay, described the path of her transgender daughter, now 9. “It would be psychologically damaging if she had to go through puberty as a male,” Ms. McClay said.

“We do not make these decisions lightly,” she added. “But these are the decisions that should be made by the families, not by the state and not by the board.”

Jude Speegle, the only transgender person who spoke, said he had known he was transgender since early childhood. “I suffered from suicidal ideation from the age of 10 to 26 and attempted suicide multiple times, thinking it was wrong to be who I was,” he said.

The Board of Medicine and osteopathic board were set to vote on Friday for the same change to the standard of care, opting to include an exception for any clinical research. But in a surprising move, the medical board struck the research exemption. That means there will be two standards in the state, one for medical doctors and another for osteopathic doctors, barring any future changes.

Anna Eskamani, a Democratic state Representative from Orange County, condemned the board’s decision during the public comment period. “I expect the legislature to be a political being, not the board of medicine,” she said.

The changes in the new standards will go into effect after a 21-day public comment period. Although the osteopathic board made an exception for children enrolled in clinical trials, no such studies have been started in Florida.

Patricia Mazzei contributed reporting.

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

A version of this article appears in print on  , Section A, Page 20 of the New York edition with the headline: Florida Restricts Doctors From Providing Gender Treatments to Minors. Order Reprints | Today’s Paper | Subscribe

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