As lawmakers considered several restrictions on transgender youth in Iowa schools, House Speaker Pat Grassley said legislation banning gender-affirming health care for minors may also come up this legislative session.
The bills discussed in subcommittees Thursday focused on LGBTQ issues in schools and the use of a transgender student’s preferred name and pronouns. But Grassley said new legislation on medical care for transgender minors may be introduced following the House Government Oversight Committee’s discussion with doctors who provide gender-affirming surgeries, procedures and treatments for people under age 18.
Dr. Katie Imborek, professor of family medicine and co-director of the University of Iowa LGBTQ+ Clinic and Dr. Dave Williams, the chief medical officer for UnityPoint Health answered questions from lawmakers about the gender-related health care provided to minors at their institutions.
“I think that based on some of the information that we’ve had shared with us, I think that there could be an expectation of seeing some legislation potentially moving forward,” Grassley said.
Grassley said the committee hearing gave a chance for medical providers to come in and share information on “why they would be doing what they’re doing” for gender-affirming care
The details of what sort of medical care would be covered under the legislation is yet to be determined, Grassley said. Transgender patients often seek gender-affirming surgeries, hormone replacement therapy and puberty blockers.
“I think at this point, again, at this point, I don’t know what that would look like,” Grassley said. “But I wouldn’t stand here and say that that’s not a possibility.”
South Dakota and Utah enacted laws banning transition-related care for minors earlier in February, while Florida imposed new rules through its medical boards to ban gender-affirming care for new minor patients. Now, six states — Arkansas, Alabama, Arizona, South Dakota, Tennessee, and Utah — have laws in place restricting access to gender-affirming care.
There are also minor transgender health care bills under consideration in 21 states, Bloomberg reports — and 11 states have bills that would criminalize the procedures.
Lawmakers hear from gender-affirming health care providers
Imborek and Williams answered questions from lawmakers about the types of medical treatment provided to minors experiencing gender dysphoria, explaining their practices for determining that gender-affirming care like surgery or hormone therapy is the correct course of action.
Minors receiving this care are not rushed into medical treatment, Imborek said, nor are they encouraged to identify as transgender. Hormones are not given to prepubescent children, and genital surgeries are not performed on minors. No care is provided without “full and unwavering consent” of the parents and thoroughly explaining to the patient and their family what changes and side effects will result from the treatment.
“Adolescents who have persistent and consistent gender dysphoria diagnosed by a mental health professional in collaboration with a care team, that usually includes their local PCP (primary care physician) and always includes their parents or guardians, are provided with medically necessary gender-affirming care,” Imborek said. “Because the evidence shows it not only helps, but can be life-saving.”
From 2020 to 2022, Williams said UnityPoint Health served 46 unique patients between ages 11 to 17. These minors were provided hormone therapy, puberty blockers and speech therapy, he said. These and all medical interventions and treatment for transgender youth are considered over an extended period of time, he said, a purposeful decision to give ample time to address the concerns of the patient and their guardians.
While genital reconstruction surgeries are not performed on minors, medical providers have performed top surgeries, removing breast tissue for people assigned female at birth, on minors. Imborek said these surgeries are performed taking into consideration how long they’ve lived in their affirmed gender, how long they’ve been on hormone therapy, and whether their parents and health care team determine that not performing the operation would cause risk to the child.
But Rep. Brooke Boden, R-Indianola, questioned whether a minor should be able to make a permanent medical decision.
“The other part that I worry about is, you know, many studies, and this isn’t new to I’m sure anybody in this room, but they say that the prefrontal cortex is not developed until well beyond 25,” Boden said. “I’m guessing that many of these people are maybe nearly a decade away from that. How can we rationalize that, at 16, you understand fully what it means to remove permanently your breasts? Forever?”
Rep. Jeff Shipley, R-Birmingham, asked how medical providers account for people who detransition — those who choose to stop transitioning, or who no longer identify as transgender. Imborek said there are studies of adults who have detransitioned which show majority of those who detransition do not make that decision because they no longer identify as transgender, but because of the difficulties transgender people face.
“They’re detransitioning because they have transitioned, and their family didn’t support them,” she said. “They transitioned and they lost their job, they transitioned and they just feel like they can’t do it anymore. And it would just be easier to live their life in in a gender that aligns with their assigned sex at birth, but they haven’t actually changed their gender identity.”
She said she worried every day about what would happen to her patients if a law was passed banning these forms of health care for people younger than 18, particularly for those who have already begun transitioning.
“Some of them have been able to really do wonderful things like go back to school, feel like they can look in the mirror, feel like they can take a shower, feel like they finally are validating who they really are,” Imborek said. “And my patients come in every day, and they tell me how worried that they are. … We would provide them with as much support and care that we could, and we would follow whatever the law ends up being.”
Bills target ‘gender identity’ instruction, affirmation in schools
Lawmakers are also moving on legislation that would prevent schools from socially affirming transgender students’ gender identity. House File 9, approved by the House Education Committee, would prevent school districts from providing accommodations like using a student’s preferred name and pronouns without written parental consent.
Senate Study Bill 1145, Gov. Kim Reynolds’ education proposal, similarly would require schools receive written consent to address students using “a nickname or a pronoun that does not correspond to the biological sex that is listed on the minor child’s official birth certificate.”
Lawmakers discussed the governor’s education bill in a subcommittee Thursday. It would prevent schools from providing instruction related to gender identity and sexual orientation – or any “sexual activity” at large – for students from kindergarten through third grade. The bill also would require the state Department of Education to compile a list of books removed from classrooms and libraries by school boards and require schools receive written consent from a minor child’s parent before accessing any book on the state removal list.
Samantha Fett, a former school board member who testified to the House Oversight Committee earlier in February, spoke in support of creating the registry. She said requiring parental permission to access certain books is not the same as banning those books. But she said the law should go further to take “obscene” materials out of Iowa school libraries, proposing schools enact standards similar to existing internet restrictions.
“My only concern is the burden falling on the parents who continue to object to the growing number of explicit materials in our school libraries,” Fett said. “And then when they’re removed, with parental permission, more will replace them, creating an ongoing cycle.”
Many of the specific books that some parents sought to remove from school libraries for inappropriate material involved discussion and depiction of LGBTQ+ identities. Parents brought up books like “Gender Queer” — a graphic novel with scenes involving masturbation, sexual activity, and gender dysphoria — as materials which should not be available in school libraries or curriculum.
Michelle Kruse, chair of the Iowa Association for School Librarians, said there’s already a system in place for selecting and reconsidering books. Putting all challenged books on a statewide list requiring parental consent would be arduous to implement and take away local control from school districts, she said.
“If a list is created a state level and that list is allowed to guide book material selection across the state at any one or all school districts, then the outcome will be detrimental to Iowa students,” Kruse said. “How can one school district possibly make the best decision for the students of another school district, when the demographics of Iowa vary so considerably?”
School districts would also be required to immediately notify the parent or guardian if their child has expressed a gender identity that is different from their sex assigned at birth, in addition to requiring consent for using a name or nickname for students that differs from their assigned gender at birth. If the school district determines notifying the child’s family of their gender identity would “likely” result in a case of child abuse, the school district would be required to immediately report their safety concerns to the Iowa Department of Health and Human Services.
Noah McIver, an 11-year-old, told lawmakers he founded a Gender and Sexuality Alliance at his elementary school because he wanted to make sure the other students had a place to learn and feel accepted about who they are. He said the provisions banning LGBTQ topics from discussion in K-3 classrooms and requiring parents sign on to honor transgender students’ preferred names and pronouns takes away the rights of students “to be who they are.”
“I’m still growing and figuring out who I am, who I could be,” McIver said. “I think all kids deserve to feel safe in schools … All kids should be able to grow and learn about who they are.”
The bill moved out of subcommittee along party lines, with Republicans recommending amendment on the child abuse reporting and the Department of Education’s role in the book list. Senate President Amy Sinclair, R-Allerton, said the bill is about putting parents back in the “driver’s seat” of decisions about their child’s health and upbringing.
“Parents are responsible for their child’s upbringing, period,” Sinclair said. “And unless there is evidence, not gut feeling, unless there’s evidence to the contrary — that that child is being harmed — then no one has a right to interfere in how that parent is parenting that child. This bill is ultimately about returning that authority for what a child learns and is taught by people who are acting in their behalf, in a place that is not home.”
The focus on LGBTQ issues related to children in this year’s legislative session is because these are the concerns parents are bringing up with their elected officials, Grassley said.
“A lot of the ideas that we come up with the ones that we’re hearing from back home,” Grassley said. “… These are ideas that we’re hearing from Iowans, that they want us to take a look in, and a lot of times, our objective in these pieces of legislation are empowering the parents to be able to make these kinds of decisions for and with their student.”
Will bills increase discrimination against LGBTQ students?
LGBTQ advocates said the governor’s bill and others barring transgender students from being addressed by their preferred name and pronouns would increase bullying and worsen the mental health of transgender students. A House subcommittee on Thursday discussed House File 367, to prohibit school districts from punishing people who do not address transgender people by their preferred name.
The legislation would stop schools from taking any disciplinary action against employees, contractors and students who refer to a transgender person by their legal name, or who do not use their preferred pronouns. Damian Thompson with Iowa Safe Schools said the bill violates the Iowa Safe Schools Act and the Iowa Civil Rights Act, both of which have gender identity enumerated as a protected class, and would put transgender students at a higher risk for discrimination.
“Both anecdotally and in the data, we see time and time again LGBTQ students are at higher rates of victimization and bullying in schools, which lead to negative academic and mental health outcomes,” Thompson said. “This bill would enable bullying from employees, other students.”
The Trevor Project, an LGBTQ suicide prevention nonprofit, found a 52% of LGBTQ middle and high students reported being bullied in a 2021 study. Students who were bullied were three times more likely to have reported attempting suicide in the past year, the study found, and students who reported their schools were affirming of their identities had 30% lower odds of being bullied.
Parents of transgender children and LGBTQ students spoke against the bill at the subcommittee meeting, saying they already faced difficulties with teachers who refused to address children using their preferred name and pronouns.
Andy Sutton, a teacher and parent of a transgender student, said the bill violates the very “parental rights” that Republican lawmakers have advocated for in other legislation.
Sutton said she has already written the letter she will be required to send to her child’s school district if the Legislature approves parental permission requirements for a child to use a different name and pronouns than what was assigned at birth. But the legislation prohibiting discipline would allow teachers to go against the parents’ wishes in cases where the family does sign off on their child’s social transition in school.
“This bill implies that you only want to honor some parents’ rights, not all,” she said. “This legislation not only ignores the notion of all parents’ rights, it continues the marginalization of trans youth and allows teachers to choose to further alienate this group of students.”
Rep. Henry Stone, R-Forest City, said the legislation is not intended to “demonize” or marginalize anyone, and does not stop teachers from choosing to use a child’s preferred name and pronouns. The bill is meant to prevent punishments, he said, like a student getting a detention or a teacher being fired for misgendering another student. Opponents to the legislation said the bill leaves LGBTQ youth with no protections against bullying.
Lindsay Maher, who spoke at the governor’s education bill subcommittee, said she was bullied for her Catholic faith in school and was called dozens of names. She said she does not believe lawmakers can “regulate away bullying.”
“So should we have had me teach the ‘Catechism of the Catholic Church’ in my school, in order for me to feel safe and not feel bullied?” Maher said. “I don’t know. I don’t think there’s anything we can do to actually get rid of bullying.”
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