Dr. Gina Sequeira first saw the protesters on a bright clear morning last September. A co-director of Seattle Children’s Gender Clinic who provides gender-affirming care to young people, Sequeira had confronted ignorance about her medical specialty in the past. But nothing had prepared her to see people outside her office, waving signs and handing out flyers warning of the “dangers” of the work she does.
“That was really, really hard for us as a clinic,” she says. “And I think it was really hard for the hospital’s patients and families who witnessed it.” Just a month later, protesters showed up again.
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Hers wasn’t the only clinic having a hard time in 2021. The LGBTQ advocacy group Human Rights Campaign has calculated that, last year, conservative lawmakers introduced over 130 anti-trans bills into state legislatures—including 35 that explicitly limited the ability of trans and gender-expansive youth to access gender-affirming care, a term that refers to holistic psychological and medical care that affirms a person’s gender identity. As of Feb. 11, the ACLU has tracked similar bills in at least 17 state legislatures this year.
Only a small group of pediatricians provide such care in the U.S., and, in this political context, those who do are often finding themselves at the receiving end of growing harassment—even as research confirms the potentially life-saving nature of the work they do. Demonstrators have organized protests like the ones at Sequeira’s clinic at other sites across the country; in Ohio, billboards have been rented spreading disinformation about affirming care—including one near a children’s hospital. Pediatricians tell TIME they have received threatening mail, have been impersonated online and have feared for their safety. And they worry such harassment campaigns could have a devastating impact on the ability of young people to access crucial medical care.
Roughly a month before the September protest, Sequeira had received an unmarked letter in the mail that gave her pause. She’d worried about the risk of anthrax, she tells TIME; of someone trying to hurt her. Eventually she gingerly opened the envelope. Inside, she found printed posters decrying gender-affirming care for children. “No child is born in the wrong body!” one read. “Who profits from this crime?”
“I was taken aback, and really kind of fearful,” Sequeira recalls. She’d seen colleagues who provided abortion receive similar abuse. But she never thought her work could become nearly as controversial. “It really made me wonder what the future of our work looks like,” she says. “Is that the path we’re going down?”
Gender-affirming care can support youth experiencing gender dysphoria, which is often described as the discomfort or distress that might occur when a person’s gender identity is inconsistent with the sex they were assigned at birth, per the Mayo Clinic. In gender-affirming care models, according to the American Academy of Pediatrics (AAP), “pediatric providers offer developmentally appropriate care that is oriented toward understanding and appreciating the youth’s gender experience.” That includes conveying the message that variations in gender identity and expression are a normal aspect of human diversity, and that, if a mental health issue does exist, it “most often stems from stigma and negative experiences rather than being intrinsic to the child.”
In young children, gender dysphoria can be treated with non-medical social and behavioral interventions, which can include allowing a child to present themselves in alignment with their gender identity by changing the way they dress, for example, or changing their given name and pronouns, explains Dr. Morissa Ladinsky, a pediatrician at the University of Alabama at Birmingham who specializes in affirming care.
Read more: Gender-Affirming Hormone Therapy for LGBTQ Youth Can Help Save Lives, Study Finds
After puberty has begun, a child experiencing gender dysphoria may also begin receiving gonadotropin-releasing hormone (GnRH) analogues—known by the term “puberty blockers.” They are “simply a pause button,” says Ladinsky, to stop the continued development of a puberty incongruent with a child’s gender identity. Used at this stage, blockers are reversible, says Ladinsky, and have been used safely for over 30 years in other pediatric conditions like central precocious puberty, which causes children to enter the developmental stage too early. Puberty blockers can help “reduce distress that may occur with the development of secondary sexual characteristics” and reduce the need for surgery in the future by holding off physical changes like an Adams apple or breast growth, according to the AAP.
When they get older, some adolescents will begin taking gender-affirming hormones, such as testosterone or estradiol. While there is some debate within the medical community on when any given young person should start hormones, the intervention has proven pivotal to the treatment of dysphoria in many adolescents. It is rare for a person under 18 to undergo any type of surgical intervention, but some may decide to pursue “top surgery”—reconstructive surgery to change the appearance of one’s chest—while they are still teenagers.
An emerging body of research has found that affirming care models can result in young people having fewer mental health concerns. As with all medical care, treatment decisions are nuanced, and, because of the age of the patients, are driven by conversations between the young person, their family and their doctor. Trans and gender expansive children cannot receive affirming medical treatment without their parent’s or guardian’s consent in the U.S. healthcare system.
Yet much of the criticism surrounding gender-affirming care operates from the misperception that young children are receiving rushed, unsupervised, irreversible treatments. In violent, visceral terms, best-selling authors, right-wing commentators, conservative social-media stars, and other influential figures have made such arguments, stirring a moral panic that has grown in recent years. The Williams Institute at UCLA estimated in April 2021 that 45,100 trans youth were at risk of losing medical care if all the bills then under consideration that intended to restrict or ban gender-affirming care were implemented into law. In the same month, Arkansas went so far as to ban pediatricians from not only providing gender-affirming care, but even providing a referral to patients. (The law is currently blocked by a federal judge.) In August, Texas Gov. Greg Abbott suggested that providing affirming care to adolescents equates to child abuse.
Mis- and disinformation about trans people has also gained airtime in conservative media, especially online. A Nov. 9 report from Media Matters found that 77% of the top-performing trans-related Facebook posts between Oct. 2020 and Sept. 2021 were on right-leaning pages, as were nearly two-thirds of all the interactions on posts about trans issues.
“There’s nothing grassroots about this at all,” argues Imara Jones, journalist and founder of TransLash Media, whose podcast the Anti-Trans Hate Machine has documented the rapid rise of anti-trans legislation in recent years. “This is a highly organized movement that is targeting trans people and trans rights.”’
Jones traces the proliferation of anti-trans bills to an umbrella organization of over 60 right-wing groups called Promise to America’s Children, which lists on its website “leading national partners” including Family Policy Alliance (the lobbying arm of longtime anti-LGBTQ group Focus on the Family), Alliance Defending Freedom (which the Southern Poverty Law Center has defined as an anti-LGBTQ hate group), and conservative think tank The Heritage Foundation. She adds that the anti-LGBTQ group Family Research Council has actively promoted anti-trans bills.
Promise to America’s Children’s website includes model legislation for policymakers titled the “Protecting Children from Experimentation Act,” which aims to criminalize gender-affirming treatment for young people. A version of the bill was introduced in Congress in 2021, though it did not advance.
Leading medical organizations have decried such legislative bans. “[We] strongly oppose any effort to criminalize or penalize physicians for providing necessary care for their patients,” read a April 2021 joint press statement from AAP, the American Academy of Family Physicians, the American College of Physicians, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association. “Physicians must be able to practice medicine that is informed by their years of medical education, training, experience, and the available evidence, freely and without threat of punishment.”
Read more: Anti-Trans Violence and Rhetoric Reached Record Highs Across America in 2021
This focus on gender-affirming pediatricians has extended beyond legislation. As disinformation and fearmongering about trans youth has surged, TIME has spoken with numerous providers who say they’ve witnessed a rise in harassment in the past two years—whether via in-person protests, online threats and cyberbullying, menacing mail, attempts to cut their research’s funding or even their medical licenses. Other gender-affirming pediatricians with whom TIME spoke refused entirely to go on the record, citing fears about the risk of violence against them and their families.
“This is shocking, shocking, shocking,” says Dr. Robert Garofalo, the head of adolescent and young adult medicine at Lurie Children’s Hospital of Chicago. “No one is prepared for this, and pediatric institutions aren’t prepared for it.”
The first known protest of gender-affirming pediatricians was in December 2020, per research by Health Liberation Now (HLN), a trans-run advocacy website that researches political impacts on trans health. But by February of 2021, anti-trans groups had announced plans to protest in Los Angeles; Chicago; Philadelphia; Dallas; Hartford, Conn.; and Ontario, Canada. Through the summer and fall of 2021, protests became a more regular occurrence. Some anti-trans groups have begun using an online interactive map that tracks the location of clinics providing gender-affirming care, per HLN’s research. Other forms of harassment stay online, but pediatricians say they are similarly frightening—and have been going on since even before the first documented in-person protest.
When Susan, a pediatric endocrinologist, got the call from her hospital’s administrative assistant in the fall of 2020, it felt like she’d been punched. (TIME is withholding Susan’s identity and that of one other provider out of concerns for their safety.) A patient’s family had contacted the hospital, the assistant said, flagging that they’d seen posts online from an account that was purporting to be Susan, but didn’t sound like her. Susan rushed to her computer, and sure enough, there was her picture and her name on a Facebook profile, apparently posting about how she regretted her treatment of transgender kids—a feeling that couldn’t be further from the truth. She found a similar fake account on YouTube pretending to be her, expressing “remorse” for her actions.
At least three other gender-affirming pediatricians were impersonated in this incident, Susan tells TIME. Their posts were made to look as if they were in conversation with each other, agreeing about the “harm” they’d done to kids.
“I don’t think I ever went into medicine thinking something like this could happen,” Susan says. “We’re always just trying to care for kids.”
Things have gotten worse. In the spring of 2021, her clinic received threats about protests. In the fall of 2021, the protests actually happened. “It really made us evaluate our safety systems for our patients, families, and staff,” she says. Susan says that she’s repeatedly been threatened with being reported to her state’s medical licensing board—though her care is not in violation of any policies—and adds that she knows gender-affirming mental-health clinicians who have faced similar harassment.
Leigh, a pediatric endocrinologist in the southeast, says people have tweeted at her asking her how she sleeps at night, arguing she is violating God’s plan.
“I am here to take care of my patients and make sure that they live longer, better, healthier lives,” she says. “And to have someone suggest something otherwise is just devastating to me.” Late at night, she’s sometimes filled with a sense of dread over where this rise in harassment could be leading. “We’ve had active shooters in the hospital where I practice for years,” she says. What if one day one of those shooters came looking for her clinic, or even her private home? “That is one of my biggest fears.”
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Garofalo, of Lurie Children’s Hospital, says that at least three of his colleagues in more conservative states reached out in 2021 asking for advice on how to deal with the harassment they were facing. They’ve told him “horror stories,” he says, including instances of receiving death threats.
Dr. Brandon Hill, the former President and CEO of Planned Parenthood Great Plains, which operates in Kansas, Missouri, Oklahoma, and Arkansas, says he’s been contacted by children’s hospital administrators in major cities across the country asking what trainings he gives abortion providers to prepare them for intense backlash and harassment. “This stuff isn’t new. The tactics that these anti-trans-care folks are using have been used to [target abortion providers],” Hill explains. “[But] I don’t think we ever thought of this being something where protesters would be outside of adolescent health centers. Ever.”
In response, many gender-affirming pediatricians have banded together to be each other’s support systems. “There are definitely colleagues who have to worry more about safety than others,” says Garofalo. “We check in on each other.” They hold wellness events and share experiences.
“We’re trying to advocate and be united together,” Susan adds. “But I can see the potential for burnout.”
The stakes couldn’t be higher. A peer-reviewed study published in the Journal of Adolescent Health on Dec. 14 found that the use of gender-affirming hormone therapy (GAHT) is significantly related to lower rates of depression, suicidal ideation, and suicide attempts among transgender and nonbinary youth. The study, led by researchers at the LGBTQ suicide prevention nonprofit The Trevor Project, also found that among young trans and nonbinary people under 18, receiving GAHT was associated with nearly 40% lower odds of having had a suicide attempt in the past year. Notably, half of the transgender and nonbinary youth surveyed said they were not receiving GAHT but wanted to.
Several providers said they worry intimidation tactics could ultimately limit the health care options available to transgender and gender expansive youth, who already often face barriers to receiving care, including stigmatization, a lack of familial support, high costs, and onerous travel to reach clinics.
“We don’t need another [hurdle],” says Sequeira. “We don’t need kids to have to walk through a gauntlet of protesters to get care.”
Dr. Janet Cathey, a gender-affirming provider who treats adults and adolescents at the Planned Parenthood in Little Rock, Ark., also worries that primary care doctors considering offering gender-affirming care might choose otherwise because they don’t want to risk wading into controversial territory. In states such as Arkansas, where gender-affirming care for youth was temporarily banned in 2021, providers may feel nervous about treating trans youth because they worry it could threaten their medical license, she says.
In a research study Sequeira has been conducting over the past year, several pediatricians expressed apprehension about starting to offer gender-affirming care, she says, in part because they feared for their safety. “Which is a shame, because we so desperately need more providers in this area,” Sequeira says. A lack of available doctors doesn’t mean young people will stop needing affirmative care, adds Susan. They might just seek that care in underground ways without the supervision of a doctor, which could be dangerous.
Such an exodus has not occurred in the field of abortion providers, despite decades of dangerous attacks that include bombing, arson, and death threats, explains David S. Cohen, a professor of law at Drexel University and the author of Living in the Crosshairs: The Untold Stories of Anti-Abortion Terrorism. However, Cohen adds, many abortion clinics have been forced to close because of financial and regulatory restraints. If the trend of anti-trans legislation continues, the same could happen to gender-affirming care providers, whether or not doctors want to leave the specialty.
“The impact of this harassment is broad. It affects clinical care. It affects research. It even affects philanthropic support, which for a lot of programs has been critical,” says Garofalo, who adds that there has already been “tremendous amount of efforts to defund” his research on gender-affirming care with the National Institute of Health.
Read more: Andraya Yearwood, a Star of Hulu’s New Changing the Game Documentary, Talks Life as a Trans Athlete
In November, the Children’s Medical Center Dallas and UT Southwestern Medical Center in Texas dissolved their six-year-old program that offered gender-affirming care to young people. (In a statement to the online news magazine LGBTQNation, the two medical centers said the decision to dissolve the program was the best option to maintain privacy for patients.) The decision came after organized protests that targeted hospital board members and argued that the care equated to child abuse, per the Texas Tribune. The program was the only one of its kind in the state.
“That’s the part that really breaks my heart about all this,” says Sequeira. “There’s a lot that’s really challenging about being an adolescent, and especially an adolescent who is finding ways to affirm their gender.”
“It just makes me so fearful to see the increasing number of protests and discrimination happening to us as providers,” she continues, “Knowing that, I can only imagine what’s happening in communities, for many, many kids.”
—With reporting by Julia Zorthian