On 22 February, the Texas governor, Greg Abbott, and state attorney general, Ken Paxton, released guidance to the state’s child protection services (CPS) classifying the provision of gender-affirming care to transgender adolescents as child abuse. The guidance threatened criminal penalties for licensed professionals, such as doctors, nurses and teachers, who fail to report suspicions of such “abuse” to the state. The policy’s implementation would also mean potentially removing trans kids from supportive parents and putting them in the state’s foster system.
Considered the standard of care for transgender youth by the major medical associations in the US, gender-affirming care can include medical interventions such as puberty blockers and hormone replacement therapies. (US medical guidelines do not recommend genital surgeries for youth under 18.)
Issuance of the guidance follows unsuccessful efforts by the Texas state legislature to enact a ban on gender-affirming care for youth. Both Abbott and Paxton are up for re-election.
The move by the Texas executive branch is not legally binding, and by Friday, district attorneys in Texas’s five largest counties had said they would not enforce it.
But the state has already begun investigating the parents of some transgender children, according to a lawsuit filed on Tuesday by the ACLU. The suit, which seeks to block the guidance from being enforced, alleges that an employee of Texas’s department of family and protective services was suspended from her job on 23 February and has since been told that she is under investigation to determine whether she and her husband “committed abuse by affirming their transgender daughter’s identity and obtaining the medically necessary health care that she needs”.
Dr Megan Mooney, a licensed psychologist based in Houston who has worked with trans youth for the past 15 years, is also a named plaintiff in the ACLU suit, which argues that complying with Abbott’s order would require “violating her professional standards of ethics and inflict serious harm and trauma on her clients”. The suit also notes that Mooney could “face prison time for making a report of child abuse when she knows child abuse is not happening”.
The Guardian spoke with Mooney on 25 February, before the lawsuit was filed, about the immediate fallout from Abbott’s announcement.
What was your reaction to the release of the ‘child abuse’ guidance?
I wish I could say I was surprised, but I wasn’t. I’m part of a working group here in Texas that focuses on LGBTQ youth and foster care specifically, and we’ve known that [Paxton has] been working on this opinion for a number of months. So I wasn’t surprised, but nonetheless, it felt like a gut punch. The language is so inflammatory and so hurtful and so factually incorrect.
Both [Paxton and Abbot] are quite desperate to be re-elected at this point. It is unfortunate that they are choosing to do so at the expense of children.
The order is not legally blinding, according to legal experts. But how do you expect it to shake up the system?
What I have seen in the past 48 hours or so is just absolute panic among mental health groups about what to do, because those of us who work alongside physicians supporting youth and their families are of course mandated reporters.
People are asking, “Do I have to report children and families and physicians that I know are doing good work? Or am I going to potentially be in violation of state laws and lose my license?” I have spent a good chunk of the past 48 hours trying to get information out through social media and all of the therapist groups I’m part of. We’re saying, “No, this is not legally binding. You don’t have to do anything different.”
In addition to that, children and families are absolutely panicked. I’ve been fielding questions from my clients and their parents about, “Do I need to prepare to move out of state? Do I need to get an attorney? What do I need to do if CPS comes to my door?”
The notices have such inflammatory language and sound like they’re enforceable, so citizens of Texas are worried about being reported for child abuse when it’s just not necessary.
What has your advice been to your clients?
It has broadly been to stay calm. This doesn’t mean anything. I’m not reporting you, nobody is reporting you, and there are huge groups of people planning to support you and take care of you as always here in the state of Texas and elsewhere. There’s lots of people, even in the conservative Texas legislature, protecting your fundamental rights.
That’s an important part that, therapeutically, I’m trying to have people focus on. It’s so important in stressful and traumatic times to be able to have a sense of hope and optimism.
Can you speak to what gender-affirming care looks like for youth of varying ages?
At its core, it’s believing children. That is the purest essence of gender-affirming care. When a child tells you who they are, you believe them, which is really no different from any of the rest of our therapy. When children tell us they’re anxious, we believe them. When children tell us they have problems focusing, we believe them. If a child tells me, “Hey, some doctor got it wrong when I was born and this isn’t who I am,” I believe them.
In addition to that, it’s supporting their journey and figuring out this particular label or identity, or outward expression means for them and for their family and how to support them in the best way to encourage positive mental health and wellbeing, social development, but also focusing on things – in Texas, unfortunately – like safety. Thinking about how we help [trans youth] have a safe path forward in school, sharing the guidance from their legal resources in Texas and outside Texas, so families and students know what their rights are.
And getting them connected with appropriate qualified and affirming medical professionals as well, so that they can get really good treatment if, and when that’s a part of their journey.
At what age might medical interventions actually happen for adolescents?
This is a highly individualized discussion and decision made with children and parents. We really are looking at whether that is something that will help them to have better mental health and physical wellbeing.
The conversation is always, “What are their individual goals?” This makes my trans and non-binary kids no different from all the rest of my clients.
So if part of their goals are to reduce secondary sex characteristics that [their bodies] naturally produce through puberty, then I give parents lots of resources, lots of research that shows them the positive mental health benefits of this treatment and what to expect from the treatments. After that I send them to at least have consultations with physicians. Have a conversation with a medical physician who can tell you about the impacts on your child’s body. You do not have to commit to anything at a first appointment with them or me for that matter, but just go get good information so you’re not Google searching HRT for kids and getting nonsense.
What is your experience with patients who have gone through pubertal suppression?
One hundred per cent positive. Not a one had a negative reaction physically or regarding mental health. That’s something that I can say, with all honesty. I have only seen positive impacts on children, either for pubertal suppression or for beginning hormone therapy as well.
One thing that I’ve run into is people who say, ‘We shouldn’t affirm a mental illness.’ And one of the points that I make is that affirming goes both ways. So if a child who was assigned male at birth says, ‘I feel like a girl’ and they feel that way for a year, you affirm that. And then if all of a sudden they say, ‘No, I thought about it and I’m actually a boy,’ you affirm that way also.
Is there a misperception that when people hear about a gender-affirming approach, they assume that it’s trying to ram a transgender identity down the child’s throat?
We don’t question cisgender children that they know their identity. We only seem to do this with our trans and non-binary kids. So why do we assume that cis kids know their gender and trans kids don’t? That questioning shows a real bias in people’s heart.
What data tells us is that kids know their gender from very early ages – three, four, and five. Since the 1960s, research has told us children consistently can distinguish between – if we’re assuming a binary – male and female, in pointing at others and identifying themselves.
So why do we think all of a sudden these children don’t understand the concept of gender or can’t label their own gender?
Why do you think there is so much opposition to gender-affirming care for minors?
At its core, it’s just a lack of understanding. People have these preconceived notions that therapists are turning kids trans, or that it’s just a fad, it’s just a phase, this is just something because of the internet or whatever.
But this isn’t new. Through art and literature and historical information, we know that trans and non-binary people have existed for thousands of years. In many other cultures that are not bound by conservative western Christian views, people are revered and as seen as higher than and better than those of us who are cisgender people.
What the internet has done is allowed children to find others like them, to give language and voice, and to know that they’re not alone. That is an incredibly valuable message for them to receive for their mental health.
Circling back to Texas, you’re telling your patients not to panic at this point. Is there a point in this process where you would suggest panicking or making moves to leave the state?
One of the really interesting pieces of advice I heard this week was [to work on] “safe folders” – letters and testimonials from physicians, mental health professionals, neighbors, spiritual leaders saying this parent is not harming their child and that their child is better off for the care they receive. So if somebody from CPS shows up at their door, that’s ready to go. If parents are looking for an action item to do right now to protect themselves, that is the conversation I am having [with my clients] this week.
If a bill passes through our legislature that somehow encodes gender-affirming care as actual child abuse, that is also a point at which I will be much more concerned for families here in Texas. I think that the problem, though, in your question, is that most families don’t have the resources to pick up and move. So finding ways for families to stay safe without uprooting their lives is another area we’ve got to focus on.
I will, in the meantime, continue to be doing the work that I do – collaborating with case workers and CPS investigators and educators and the general public so that people really understand that gender-affirming care is medically necessary care and is life-saving care and is most certainly not abuse.
This interview has been edited for length and clarity
