There is clearly going to be one story that blots out the sun for a while, and it will dominate conversation in the shebeen as well. However, there’s still repression going on in this country, chiefly in Texas, where Governor Greg Abbott, surely one of the least excusable humans in our politics, directed his state agencies to define gender-affirming care as child abuse. He also seeks to turn doctors—and private citizens—into agents of the state by requiring them to inform on any young person seeking to transition.
This prompted Friend of the Blog Dr. Kenneth Starnes, an ER physician down in winter’s bone country where Missouri and Arkansas meet, to send along a story from his own experience that illustrates the kind of human tragedies that Abbott’s directive makes inevitable. Read and learn thereby.
I see fear a lot in the emergency department, more often than any other emotion. Which makes sense—people are there because they’re afraid of something. “Is this chest pain a heart attack?” “Why does my kid have a fever?” “Is this stomachache cancer?” One of the best parts of my job is that I get to make people unafraid. I can tell them that either what they’re in for is pretty easily fixable, or at the least probably isn’t serious. With most of my patients, that’s really why they’re in the ER: for someone like me to tell them, “Not today.”
Sometimes, though, I see Real Fear. The kind that a few professional words and normal bloodwork can’t erase. When I tell someone they have to get transferred to go see the heart surgeon, or when I tell them about the tumor I see on the CT scan, I can’t just hold their hand or draw a picture. I have to look in their eyes and see how wide a pupil can get when the body’s response betrays the calm they’re trying to maintain.
Recently I saw Real Fear in all its terrible might. We frequently see visits from people who are in mental health crisis. Because our medical system is irretrievably broken, there is very little outpatient help, particularly in the rural areas where I work. People come to the ER for help. (The First Law of Emergency Medicine: If you don’t know what else to do with someone, bring them to the ER, since we legally have to see everyone). Mostly all I can do is determine if they are a threat to themselves or others. If so, I'll put a legal hold on them and get them admitted to a psych facility, a process that lately can take days. When I see kids, it’s particularly hard. Not only are resources even more inadequate, but the stories are absolutely heartbreaking.
A young person was brought in after an attempt at an overdose—not terribly uncommon, sadly—and fortunately, from a medical perspective, they would almost certainly be fine. So my job then was to assess the risk they were in for continued harm. In training, we are taught the common questions to ask: history of attempts, family history, recent stressors, substance use, access to firearms, etc. But what commonly goes unasked, particularly in younger children, are questions around sexual orientation or gender identity. Studies have shown that LGBTQIA youth have a very high rate of depression and suicidal thoughts and attempts, so knowing that information seems like something I, or the psychiatrist who eventually sees them, would need to know. Sometimes it’s fairly obvious, but sometimes it’s not, so I ask everyone. I get a lot of questions from patients, parents, and staff about this, and it’s clear I’m one of the few doctors who gets into these details.
Usually, I have parents step out of the room when I ask these questions, mostly because few kids want to talk about sex with mom in the room, but also to make sure there’s no other issues that might come up that they might not be as comfortable discussing. I always explain the concept of doctor-patient confidentiality, and tell them that unless they say otherwise, this is just between me and them.
So we got to the part of the interview where I asked this kid, “Do you consider yourself a boy, or a girl, or both, or neither?” Usually kids quickly tell me they are cisgender, often with an “of course, why are you asking” eye-roll. But in this case, the kid in front of me paused for several seconds and, in one of the quietest voices I have ever heard, told me they were trans. That's when I saw those eyes widen, the pulse on the monitor jumped up 20 beats, and their skin flushed. I know this reaction. This is Real Fear. I was the first adult they had ever told this to. They begged me not to tell anyone, and the tears started when they mentioned their father. I could tell that this was information that they felt would have real consequences at home. When I met dad, I understood that concern. This child was in Real Fear for their life, security, and safety over this.
On the other hand, I have met extremely supportive parents that use the names and pronouns their kids prefer, who are seeking gender-affirming care, and though it’s clearly hard for them, are fighting to support their kids. I’ve also witnessed some real moments. Like the father who used his trans daughter’s name for the first time in my ER room, and cried in my office for 10 minutes when I told them that this single act may have saved her life.
And I cried right there with him.
My job is to save lives, and sometimes it takes big procedures and drugs. Sometimes it just takes saying “her” to someone, and being the first adult to do it.
So you can imagine my blind rage at the Texas governor’s decree classifying any gender-affirming therapy as child abuse, mandating reporting and investigation by the state. In order to score political points and run as far to the right as possible, life-saving therapy or procedures would be considered a reason to remove a child from a home, and warrant investigation of a doctor. Therapy that, according to The Trevor Project, substantially reduces the risk of suicide and depression in trans and non-binary youth. 82 percent of transgender individuals have considered suicide, and 40 percent have attempted it.
Not satisfied with excluding transgender youth from playing sports, Greg Abbott and his ilk now want to treat a well-studied and safe therapy like physical violence and neglect. And they want people like me, school counselors, nurses, teachers, etc to help him with it. Right now, the law doesn’t require me to report a child who simply self-identifies to me as trans or non-binary. But with this and the “don’t say gay” bills in Florida and other places, it wouldn’t surprise me if similar laws emerge in my state. (I’m not a fan of the “slippery slope” argument, but sometimes things do actually slide downhill). If this is the case, I will no longer be able to practice in states with these laws. I would sooner lose my license, or even be prosecuted, than deny the oath I took: “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”
Remember when people on the right were up in arms about keeping the government out of the doctor-patient relationship? I hate to come to conclusions before all the evidence is back, but I feel that might not have been totally on the level. Make no mistake, this ruling will cost lives. Pure and simple. The governor is a willing accessory, and he’s asking the people who have dedicated their lives to saving children to read out the warrant. I have Real Fear for these children now, and no one’s coming to hold my hand, or the hands of these children and tell us it’s OK.
Charles P Pierce is the author of four books, most recently Idiot America, and has been a working journalist since 1976. He lives near Boston and has three children.
