photo by: Kim Callahan/Journal-World

The Douglas County Judicial and Law Enforcement Center is pictured on Sept. 4, 2024.

One child struggling with gender dysphoria was “slicing his arms and showering in the dark” before getting treatment, Dr. Angela Turpin said. Another “could not make eye contact with anyone” and constantly apologized.

But that all changed when they received gender-affirming care, Turpin, of the Gender Pathways clinic with Children’s Mercy Hospital, testified Wednesday in Douglas County District Court. They were enjoying life more, participating in competitions and activities like junior ROTC.

“We see a thriving that wasn’t there before,” she said.

Before Gender Pathways opened, families like those in Kansas and Missouri had nowhere to go. “There were no options,” she said. And now, for many of those patients, it once again looks like there are no options.

That’s because of Senate Bill 63, which was passed by the Kansas Legislature earlier this year over Gov. Laura Kelly’s veto and bans gender-affirming care such as puberty blockers, hormone therapies or surgeries for minors. Turpin and several other medical experts were on the stand on Wednesday for an evidentiary hearing in a lawsuit filed against the state of Kansas by the American Civil Liberties Union on behalf of two transgender teenagers and their families, one of whom is from Douglas County. The ACLU is seeking an injunction to block the law from being enforced.

Since SB 63’s passage, Turpin said in response to questions from ACLU attorney Harper Seldin, many of the clinic’s patients have remained. But they’re not doing well. She said some patients felt like society was rejecting them.

“Anxiety is back,” she said. “Depression is back.”

Another one of the several physicians whom the plaintiff’s attorneys called to testify on Wednesday, Cincinnati Children’s Hospital endocrinologist Dr. Sarah Corathers, painted a similar picture of what happens when children with gender dysphoria have to stop treatment.

“It looks like worsening depression, anxiety,” she said. “… It looks like tearful encounters in the clinic with both children and parents. It is very challenging to see, as a clinician, when treatment is available and is not provided.”

One of the attorneys representing the state of Kansas, Chad Blomberg, asked whether Corathers opposed gender-affirming care bans.

“I support care for children,” she answered. “… I support care that is safe, effective and helps their well-being.”

• • •

In her testimony, Turpin described how long it took for children to start receiving puberty-blocking drugs or other gender-affirming treatment at Gender Pathways. Her message was that the process is deliberate and can take a while.

Children had to be referred to the clinic by another provider to become patients, she said, and they would generally have to be exhibiting symptoms for at least a year. The median amount of time the child had felt symptoms of gender dysphoria before presenting to the clinic, she said, was four years; the median amount of time their parents had known about it was about two and a half years.

She rejected the idea that it was too easy to access this kind of care. “We take a long time figuring out where that individual’s needs are,” she said.

And she emphatically denied that the clinic had pressured parents to accept treatment for their kids. She said that in talking with parents, the clinic didn’t lead with statistics about suicide among transgender youth, for example. And when “a child is crying and they desperately want care,” but their parents aren’t ready, the clinic wouldn’t try to get the parents on board.

“We are extremely careful not to be coercive,” Turpin testified. “We do not use the word ‘recommend.'”

• • •

Attorneys for both the plaintiffs and the state had questions about the levels of evidence supporting gender-affirming treatment. One of the experts who testified about that was bioethicist and pediatric hospitalist Dr. Armand H. Matheny Antommaria. Like Corathers, Antommaria works at Cincinnati Children’s Hospital in Ohio, a state that has its own gender-affirming care ban.

Much of what Antommaria talked about had to do with the standards of evidence that are used to create guidelines for medical professionals. In response to questions from both sides’ attorneys, he said much of the scientific evidence surrounding gender-affirming care is “low to very low quality evidence.”

That led Andrew Nussbaum, an attorney representing the state, to ask whether, when legislators try to make policy on gender-affirming care, “what they’re faced with in the aggregate is a body of low-quality evidence.”

Antommaria clarified later, however, that terms like “low quality” don’t mean the same thing to specialists as they do to laypeople.

“They have a technical meaning and do not mean poor or inadequate,” he said.

Low-quality evidence can be “the best available evidence,” he said, and it’s frequently used to create guidelines for practitioners to follow. For gender-affirming care in particular, he said, it wouldn’t necessarily be practical or ethical to generate higher-quality evidence, such as blinded trials where patients aren’t supposed to know whether they’re getting the treatment or a placebo.

“You’re either going through puberty or not going through puberty,” he said. “You couldn’t adequately blind that kind of trial.”

• • •

Much of the questioning also focused on the effects of puberty-blocking drugs and how stopping these drugs would affect a child’s development.

They asked questions about things like bone mass and children’s growth spurts, and how pausing puberty with blockers and then starting puberty later could affect these in the long run. Corathers said that even while on the medications, children would keep growing and developing throughout adolescence.

“They continue to grow. They continue to gain bone mass. They continue to develop their brain,” she said.

She also pointed to kids who naturally go through puberty later than their peers, and said that “their outcomes are quite good.”

“The beauty of pediatrics is variation,” she said.

Blomberg had another question about those “late bloomers.” They can experience distress, too, at lagging behind their peers, he said, and asked whether puberty blockers were putting kids in the same situation.

“No,” Corathers said. She said the circumstances in which puberty blockers would be used are “quite distinct” from those cases.

She recalled a patient who had started on blockers, continued for about two years and then decided to stop. In that case, though, both the young person and their parent agreed that the time spent on blockers that allowed the child time to explore their gender identity “was invaluable.”

Children who are experiencing gender dysphoria aren’t worried about lagging behind their peers, Turpin said. They’re worried about watching the changes their friends of the same gender identity go through and seeing the opposite thing happen to them.

“What you find is their bodies are betraying them,” she said.

“Which is way more stressful,” she added, “than having nothing happen.”

The hearing is in Judge Carl Folsom III’s courtroom and will continue on Thursday morning.