On January 28, President Donald Trump signed an executive order attempting to sharply curtail access to gender-affirming care for transgender minors and 18-year-olds. The order has been decried and challenged by the ACLU and three Democratic state attorneys general; 15 others released a statement opposing Trump’s order. But even with the legality and ethics of the order in question, some hospitals are choosing to comply in advance.
Alex T. Dworak, a family medicine physician in Omaha, Nebraska, was stunned by the sheer scale of misinformation in the order. Dworak spends his days treating a variety of patients, including trans youth and adults—and what the order describes is as far from his everyday experience as it is from the expert consensus that such care is medically necessary and sometimes lifesaving. In addition to his seven years of standard medical training, Dworak opted to pursue more than 100 hours of continuing education from Harvard Medical School to better serve LGBTQ+ patients, and has led numerous panels on the topic.
Dworak emphasized how extensive the process to start gender-affirming care is—involving written consent by all of a young person’s legal guardians, and a letter of support by a therapist who has confirmed their diagnosis and ability to give informed assent, as well as the family’s.
Dworak explains that working with trans patients has made him a better doctor across the board. “My experience caring for trans youth has taught me a great deal about personalizing my care and not making assumptions,” he says, “It makes me even better at taking care of each patient as an individual.”
“When queer kids are involved, suddenly my professionalism, training, and dedication count for nothing.”
As a doctor who never skipped a day of work during COVID, and received praise for it, Dworak laments that “it remains extremely offensive to me that I am good enough to risk my life and save many lives” in his work on the front lines of the pandemic, “and yet when queer kids are involved, suddenly my professionalism, training, and dedication count for nothing.”
In an email conversation, Dworak set the record straight on some of the falsehoods in Trump’s executive order—and what it’s like to be a doctor for trans folks in the current climate.
This executive order is dense, so I’d like to unpack it phrase-by-phrase. Let’s start with “chemical and surgical mutilation.”
The terms used by the executive order are false. Transgender medical care uses the exact same medications used for non-trans adults and youth—and indeed, children. As far as surgeries, genital surgeries do not happen to trans children in my experience and would be outside the [previously existing] guidelines as well. The only surgery done on trans boys—which is still very rare—is top surgery or chest masculinization. The exact same surgery is done for cis boys—also rarely—with gynecomastia. There is no mention of these terms being applied to any children who are not trans for the exact same care; it is objectively discriminatory as well as sensationalist.
What does gender-affirming care actually involve?
Gender affirming care is personal, individualized and holistic care and actually happens for cis and trans people. For cis people, it involves health and nutrition counseling, defining and supporting individual health goals with the patient being in charge, hormone therapy with the hormone that suits and supports their gender identity (testosterone or estrogen) and lab monitoring, overall medical care in the case of deficiencies that can occur for a variety of reasons, as well as elective surgeries done with full informed consent for adults. These have beneficial physical and mental health effects.
It also involves treating people respectfully. It involves keeping an accurate anatomical inventory for age and body-part-appropriate cancer screening per expert consensus guidelines. It involves reproductive health and family planning as desired by each individual patient. It is interdisciplinary management with specialists and other health professionals as individually appropriate for the patient. Gender affirming care for trans people is exactly the same except that trans women also often choose testosterone suppression.
The order defines children as “individuals under 19 years of age.” Can you think of any medical reason for grouping 18-year-olds in with minors? Does that happen with any other care?
It is not clear to me why the order targets people under 19. My state of Nebraska treats 19 as the age of majority, but to my knowledge only four other states do so. Voting, military service, and other rights are nationally conferred at 18. If a person is mature enough to volunteer or be drafted for potentially deadly combat exposure, I do not know why medical care would be any different.
The order frequently uses the term “rapid-onset gender dysphoria,” a hypothesis that some adolescents experience gender dysphoria and identify as transgender due to social influences. As I understand, the research on this has been retracted. Is this correct? What else is there to understand about it?
Lead study author Lisa Littman conducted her research in a way so egregious that her paper was summarily retracted. Her assertions are not supported by more robust literature and do not comport with my clinical experience either. Her study was a questionnaire posted on anti-trans sites, soliciting the perceptions of parents who frequented those sites. This is both a selection bias and a basic error in that no input from the study population in question was obtained. Her site lists her as serving on the advisory board of Genspect, which is an SPLC-designated anti-LGBTQ hate group. For these reasons, I do not view her as a clinically neutral or trustworthy source of information.
The order also asserts that “Countless children soon regret that they have been mutilated.” In your own practice, have you seen many children experiencing such a feeling? What are the risks of detransition, and who detransitions?
Retransitions are uncommon in the literature in pediatric age groups specifically, and most often occurred before age 10 when they did happen, according to this study, which would be well before even reversible hormonal blockade would be indicated—and thus there would be zero bodily changes, making regret about one’s body from medical intervention impossible. The use of extreme, incorrect and misleading language associated with farm and industrial machinery accidents is again noted, and I believe it is intentional fearmongering.
The order also speaks several times about risks to fertility. What is the real risk to fertility for youth receiving gender-affirming care? How do clinicians work with youth and their families to preserve young people’s options to have children?
The focus on fertility treats people as valuable only insofar as they produce babies. This is a feature of right-wing European populist parties and also touted by American leaders on the right wing—and linked to efforts to ban abortion. In the care of transgender people, I always ask what each individual’s fertility and family goals are as I get to know them. I advise every patient considering gender-affirming hormone therapy of the effects on fertility and offer a trans-friendly expert OB-GYN and reproductive endocrinologist to them and their families by name. For youth presenting at the onset of puberty, I do additional counseling to highlight that not experiencing extensive natal puberty may impair future fertility compared to someone who starts gender-affirming hormone treatment later in puberty or adulthood, and have a nuanced discussion with the patient and their parents and/or guardians.
The order directs federal agencies to rescind guidance that relies on the World Professional Association of Transgender Healthcare‘s Standards of Care, which it characterizes as “junk science.”
The WPATH Standards are part of the extensive literature and guidelines I use in this care. WPATH standards are not “junk science.” They were carefully designed, refined from previous editions going back decades to the mid-20th century, and had interdisciplinary input from doctors, researchers, stakeholders and trans community members with an extensive revision process that is honest, community focused and intellectually sound.
The order directs the Secretary of Health and Human Services to publish a review on “existing literature on best practices for promoting the health of children who assert gender dysphoria, rapid-onset gender dysphoria, or other identity-based confusion.” A similar process happened in your state of Nebraska. What was the outcome? Do you have any concerns about this on a federal level?
I am extremely concerned about this process, given the overly partisan and hate-filled rhetoric of this administration. In Nebraska, a FOIA request led to my learning that problematic and overtly transphobic figures like Kenneth Zucker and Andre Van Mol were included on equal footing [in conducting the review] with trans people and clinicians that have earned and retained the trust of trans patients. [The Nebraska regulations] have a requirement for 40 hours of therapy prior to youth treatment—which has no foundation in the literature—and requires a seven-day waiting period. Otherwise, the [state] guidelines reflect my practice fairly closely, which I attribute to my speaking at length with the [state’s chief medical officer] about my clinic’s existing practices in the lead-up to Nebraska’s laws, and him listening to me.
Still, I believe we have great reason to be concerned, because the Trump administration has made extremely overtly hateful and erasing statements and picked uniquely unqualified individuals to nominate for positions of great public authority. The hand-picked authors of any “scientific review” that this administration publishes are extremely likely to be ultra-partisan and hateful.
The order directs “institutions receiving Federal research or education grants,” including medical schools and hospitals, to no longer perform gender-affirming care. A lot of folks don’t realize how much federal funding goes into the medical world. How widespread will the effect be?
Banning any federal funding going to any institution which provides pediatric gender-affirming care would have catastrophic nationwide effects. Teaching hospitals and university clinics, as well as federally qualified health centers and military health institutions would all be affected. If Medicare and Medicaid were also included, that would impact private clinics too. This would dramatically narrow options to receive care, and is already having a chilling effect in other states even before the order, where governors can intimidate institutions that receive state funds, essentially blackmailing them into abandoning trans people publicly by not advertising services or joining pride events. This would be catastrophic for youth and adults, and constitute an extreme government overreach into some of the most personal and private details of people’s medical care, in addition to violating parental rights.
Gender-affirming care for youth has already been restricted by legislation in your home state of Nebraska. What has that experience taught you?
In Nebraska, it has shown me that there are surprising amounts of compassion, understanding and a desire to learn with kindness in areas one might not expect. Of late, as certain Nebraska politicians have caught the nationwide transphobic fever—which is now pathognomonic of being part of the Republican majority—it has also given me endless opportunities to express my values and stand up for and with my patients.
I grew up in Nebraska as the son of a doctor and a nurse and the grandson of World War II veterans. I have done all my training and practice here, and have hundreds upon hundreds of other healthcare professionals across the state and elsewhere in the US whose careers it has been my privilege to assist.
“There is…abundant evidence that denial of medically necessary care is harmful and promotes suicidal ideation.”
When politicians with no medical training or expertise of any kind assert that they know better than me, and they control me, it has felt like I was in an abusive relationship with the great state that has been my only home, and where I hoped to eventually retire and live out my life. But there is still great kindness in Nebraska, and I decided to stay because of that, to be near my extended family, and because I got tired of ceding control in my mind and decided to say, “No. I am the doctor, and I am not leaving my patients and my community.”
Now, with this nationwide chaos and fear-based assault on trans rights and medical professionals like me who dare to buck the patriarchy by caring for trans people as actual human beings, I feel even more convinced that staying was the right move. This is where my roots and my connections are. This is my home and where I can make the biggest difference, And there is no safety anywhere, and so this is as good a place as any to stand and fight for my rights and my sincerely held beliefs and my patients.
Trump has issued an executive order attacking “social transitioning” in schools, which he equates to “unlawfully practicing medicine by offering diagnoses and treatment without the requisite license.” Is social transition medical care?
Social transition is an important part of gender care, but only insofar as accepting and being kind to and not bullying any child is important. If social transition is characterized as medical care, the absurdities quickly become apparent: Is calling a child by a nickname or by their middle name practicing medicine without a license? I have had long hair for most of my life; is that “radical left indoctrination and gender ideology”? Such nonsense.
There is no medicine or surgery involved and it is completely reversible. It is plainly clear that “gender ideology” really means “we hate all queer people and erroneously think that we can bully children into not being queer,” even though there is abundant evidence of harm in forcing people of any age to be inauthentic in important areas of their lives.
The journalist Mira Lazine has reported that hospitals are withdrawing access to gender-affirming care, but leaving retaining access to mental healthcare. Is there evidence that psychotherapy alone is effective in treating gender dysphoria?
There is no evidence that psychotherapy alone is effective in treating gender dysphoria, and abundant evidence that denial of medically necessary care is harmful and promotes suicidal ideation.
Anything else to add?
This care is some of the most careful and nuanced that I provide. It is done for fully assenting and consenting families. It is an important aspect of my care for the underserved, which along with teaching, have been the defining features of my career and which I hope will be my legacy. All of this I have done because I love learning—and my patients needed that service, so I became skilled to provide it.
