Political pressure led to shutdown of Texas’ largest gender-affirming care program

This story was originally published by The 19th.

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Leaders of a now-defunct health clinic — known for years as the largest program of its kind for transgender youth in Texas — came under pressure to restrict gender-affirming care from the governor’s office and a state House investigative committee, according to recordings of internal meetings among hospital leadership and staff obtained by The 19th.

Hospital administrators and doctors at GENder Education and Care, Interdisciplinary Support (GENECIS), a state-run medical institution, struggled to reconcile halting care with the knowledge that doing so could severely jeopardize the mental health of their patients, the recordings reflect.

GENECIS, which was jointly run by the University of Texas Southwestern Medical Center and Children’s Medical Center Dallas, quietly closed to new patients in November, with all references removed from the Children’s Health website. The 19th obtained nearly five hours of meetings among UT Southwestern leadership and staff, as well as staff and leadership at Children’s Medical Center and GENECIS employees, that took place during 2021 and 2022.

The shuttering of GENECIS is part of Texas officials’ efforts to restrict health care and full access to services for trans youth. Gov. Greg Abbott called three special sessions of the Texas legislature that prioritized anti-trans legislation, pledged to take action against gender-affirming care for trans youth, and has backed the state attorney general’s interpretation that giving puberty suppressing drugs and hormone therapy to trans youth is child abuse. These moves have put multiple parents seeking care for their trans children under investigation by the state. On a March 2 call with reporters, Abbott’s campaign reportedly described the push to investigate parents of trans kids as a winning issue.

In an emailed statement, a UT Southwestern spokesperson said that hospital leadership was not contacted by the governor himself about GENECIS and its services. When asked if leadership was contacted by the governor’s office, the spokesperson said that inquiries into actions by the governor’s office should be directed there. The governor’s office and Children’s Medical Center Dallas did not respond to requests for comment.

Texas Attorney General Ken Paxton’s nonbinding opinion about gender-affirming care was issued in response to state Rep. Matt Krause, chair of the Texas House General Investigating Committee, who asked the attorney general last August whether puberty-suppressing drugs and hormone therapy count as child abuse. Krause had also written a letter dated June 30 to the GENECIS clinic, obtained by The 19th, saying that he had begun an inquiry into their work as part of an investigation into gender-affirming care in Texas. Krause did not respond to requests for comment.

The hospital leadership and staff at GENECIS began to discuss the political pressure on the clinic as early as July, according to the recordings, as the Texas investigative committee looked into their work and the governor’s office probed for more information.

Meetings among hospital leadership and staff beginning last summer portray disarray and distress. They worried that halting care could lead to suicides and poor mental health among trans youth in a state with few options.

“How can we minimize the risk of suicidality in patients who could otherwise have come into GENECIS? I think that’s a very high priority,” Dr. Perrin White, director of pediatric endocrinology at UTSW, said at a November meeting.

“We’re taking away the life-saving medical care for the new patients,” one GENECIS employee said in response. “If we’re mitigating suicidality, let’s be clear, it’s because in large part, we’re taking away medical care.”

The GENECIS team was instructed by UT Southwestern leadership in November to stop prescribing hormone treatment and puberty blockers to new patients, several days after the website suddenly came down on November 12. Existing patients were allowed to continue all treatment, but new patients would only be able to access psychiatric evaluation and counseling, and be evaluated for gender dysphoria.

Physicians and staff debated how to maintain some semblance of care for trans youth under their new normal. Several GENECIS staff members raised concerns that the program was not designed to offer psychological care alone — and that the ultimate point of evaluating patients’ mental health is to determine whether they can receive hormone treatment or puberty blockers, considered life-saving care by families of trans kids and many of the physicians who work with them.

Access to hormone therapy and puberty-suppressing drugs, widely recommended by medical authorities, is linked to lower rates of suicidal ideation and improved mental health among trans youth. Kids who received one year of hormone therapy through GENECIS reported small to moderate improvements in symptoms of depression, per research by leaders of the program published in the American Academy of Pediatrics in March 2020.

Evan Singleton, 19, who lives outside Dallas, told The 19th that he believes the gender-affirming care he received through GENECIS — puberty blockers and hormone treatment — saved his life.

“I feel scared and sorry for these kids that can’t get the help that they need,” he said. For him, starting puberty blockers soon after he turned 10 was a relief. His mother, Mela, added that finding a way to halt her son’s puberty afforded her time to learn the best course of action for her child’s future, while halting the extreme emotional distress caused by his puberty.

Another recurring concern discussed among staff was the potential for the clinic, or even individual physicians, to face lawsuits after denying hormone treatment to trans kids while prescribing that same treatment to cisgender kids with precocious puberty.

Although UT Southwestern will not provide puberty blockers and hormone treatment to new patients if they are diagnosed with gender dysphoria, the hospital does provide hormone therapy to patients with precocious puberty, spokesperson Rian Russell said in a statement, pointing to FDA approval as a reason for the discrepancy.

UT Southwestern is tied to Texas officials. The medical center relies on state funding that is approved through the governor’s office. Texas’ governor also appoints members for the governing body for the University of Texas System, pending approval by the state Senate.

Dr. John Warner, the executive vice president of health system affairs at UT Southwestern, referred to that unique pressure faced by UT Southwestern as a state agency in the recorded meetings. A senior leadership official with the Children’s Medical Center also shared that sentiment in a meeting earlier this year. Both men, in addition to White, spoke about pressure and questioning into the GENECIS program by the governor’s office.

Prior to July, the governor’s office had requested information about the clinic with “an expectation that something different would occur,” Warner later told his colleagues in November.

“We weren’t sure what that was going to mean,” he continued in the recorded meeting. “We thought that might mean that portrayed something that would come via this legislative session, so again, we’re fortunate in that it did not, because it gives us a little room to work,” Warner said.

Through the meetings, details of how the governor’s office purportedly reached out to the hospital or what the governor’s office said were not clear.

The 19th independently identified Warner from introductions made for him during a recorded meeting as well as public videos of him speaking professionally. White was also identified independently by The 19th from public videos of him discussing his work. White offered to respond through official channels at UT Southwestern, but the medical center’s press office had not responded as of publication time. Warner did not respond to requests for comment.

“I think people will come after it until it’s gone,” Warner said at the November meeting. During the previous legislative session, the clinic had come under significant pressure from state legislators, plus scrutiny from the governor’s office, he said.

Although Abbott’s third special legislative session did not result in the worst-case scenario outlined by Warner — GENECIS being “eliminated entirely” through legislative amendment — he explained to colleagues that he still did not believe the clinic would be allowed to continue without some modifications.

The pressure from Krause, who headed the investigative committee looking into GENECIS, was a precursor of what would come in 2022. In his June 30 letter, Krause had asked the clinic to provide details about their services, including what age groups the clinic treats, what other practitioners the clinic makes referrals to, and for copies of consent forms required of patients. All of these questions were discussed by UT Southwestern leadership and staff in a meeting that summer, with hospital leaders voicing particular concerns about whether the clinic could continue to provide gender-affirming care while beholden to the state.

Over the course of three special sessions from July to October last year, Republicans in Texas introduced nearly 50 bills that proposed to restrict access to gender-affirming care or school sports for trans youth, in addition to a few other bills focused on birth certificates — in total, triple the number of anti-trans bills of any other state in 2021. One restricting trans youth’s sports participation passed.

Then the GENECIS website disappeared.

During meetings in November, attorneys representing UT Southwestern had assured hospital leadership that halting gender-affirming care for new trans patients would not make them liable if faced with a lawsuit.

But physicians and staff with GENECIS still expressed discomfort about what they were being asked to do — and what it would mean for the trans youth they treat.

GENECIS is an early example of a trend unfolding across Texas in the wake of Paxton’s nonbinding opinion: clinics shuttering gender-affirming care for minors in response to state pressure.

Texas Children’s Hospital, a nonprofit hospital in Houston, announced last week it will cease gender-affirming care in response to Abbott’s call to investigate families to avoid “potential criminal legal ramifications” for health care staff and families seeking care, spokesperson Natasha Barrett emailed in a statement.

One parent of a trans child living in Texas, who asked to remain anonymous due to fear of being reported to the state and investigated, told The 19th that the Legacy Community Health in Houston stopped prescribing hormone treatment or puberty blockers for trans minors on Monday, March 1. They could not get access to their son’s testosterone prescription for three days until the clinic resumed prescriptions on Wednesday.

The parent said they weren’t told why the clinic started providing prescriptions again, and that they did not receive any written communication when their son’s prescription was first denied. Legacy Community Health clinic did not respond to requests for comment.

Last week, as the Biden administration admonished Texas for its push to investigate the parents of trans youth, the Department of Health and Human Services encouraged health care providers who believe that they have been unlawfully restricted from providing gender-affirming care to patients based on their gender identity to file a complaint with the agency’s office of civil rights.

“We are evaluating the tools at our disposal to protect trans and gender diverse youth in Texas,” HHS Secretary Xavier Becerra said in a statement.

Charis Sharp, a 21-year-old psychology student living in Hawaii, told The 19th that care she received through GENECIS — puberty blockers when she was 12, and then hormone treatment — were a critical lifeline at a time when she was suicidal due to gender dysphoria and discrimination she faced from her peers.

“The fact that they’re no longer allowed to accept new patients, this can have disastrous impacts on these children's mental health, and I know it because that was me,” she said.

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