Gender-affirming care for youth is banned in Iowa, North Dakota and South Dakota. It is prohibited in more than 20 other states across the country as well, after a a wave of legislation over the last two years.

Then there’s Minnesota, which went in the opposite direction, passing last year’s bill which made the state a “trans haven.”

“We are this island in the middle of states that ban and restrict access,” says Dr. Kelsey Leonardsmithdirector of youth gender care at the Family Tree Clinic in Minneapolis. She says it’s difficult to provide this care in the political spotlight.

“You have two choices: You can be afraid and say, ‘I don’t know if we can do this,'” she says. “Or you can take a deep breath and say: we know the work we do. We looked at the research. We’ve been doing this for a long time now and we’re doing a good job: our patients are crying tears of joy in this building.

Providers like Family Tree and others that NPR spoke with said they are adapting as quickly as possible to accommodate an influx of out-of-state patients.

Instead of freezing out of fear, Leonardsmith says, “the other thing you can do is say, ‘We’re going to do this, we’re going to do it more, and we’re going to teach everyone how to do it.’ . do it too.

It is through this attitude that Family Tree has come to lead the Midwest Trans Health Education Network. So far, they have trained around 50 healthcare providers from across the region, including rural areas. Over the course of eight virtual sessions, they prepare members of each cohort to be able to care for trans patients.

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This goes beyond relevant medical training and also affects part of the bureaucracy.

“A lot of it is, ‘Here, these are all the patient documents, the intake forms, the sample letters for when you have to fight with an insurance company,'” Leonardsmith says. She co-leads the initiative with project manager Dylan Flunker.

Trans patients from across the region are now heading to Minnesota and creating challenges, according to clinic staff.

Last year, “just at our small clinic, we saw over 200 people from out of state,” says Family Tree’s executive director. Annie Van Avery.

Children’s Hospital of Minnesota has also seen an influx, with a 30% increase in calls to its gender health program and the hospital hiring more clinicians to help. A Minneapolis pediatrician told NPR he personally treats 15 trans patients who come from out of state.

The bans have led to financial hardship for both patients and providers. For patients, traveling out of state to receive care can mean fewer follow-ups, as well as travel costs for things like gas and hotel rooms, as well as time off work. For hospitals and clinics, patients’ health insurance often does not reimburse foreign doctors.

Family Tree uses a sliding scale and doesn’t turn away patients who can’t pay, Van Avery says. “At this point, we provide a service to other states and we want to be able to maintain that access, but it presents a huge financial burden and challenge,” she says.

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Across the city, Dr. Kade Goepferdpediatrician who runs the gender health program at Children’s Minnesota, says many of their patients’ families ended up moving to the state, rather than traveling there periodically for appointments.

“They’re Minnesotans now,” Goepferd says. “Knowing they were going to (move), they called and signed up for our waiting list in advance.” Even after hiring more clinical staff, the wait for the program is still about a year.

For families with young children, such as 5-year-olds who already strongly express a transgender or non-binary identity, it is possible to wait several months before an appointment because gender-affirming care at this age is not are just words.

“Some families call us with their children this young to ask, ‘How can I talk to the grandparents?’ Should they choose their clothes? And if they ask to be called by a different name, how can we handle that? “So they are just looking for support,” says Goepferd.

Timing becomes much more important as patients age. Trans teens and their families may decide to use puberty-blocking medications or cross-sex hormones, or both. (The surgery is very rare for minors.)

These are the type of interventions that some lawmakers oppose, despite the fact that major U.S. medical organizations, including the American Medical Association and the American Academy of Pediatrics, access to support.

When lawmakers in Iowa, Minnesota’s southern neighbor, debated that state’s ban last March, the bill’s sponsor, Republican Steven Holt. explained why he believed the ban was necessary. “Our children deserve time to grow into themselves, to find themselves, to go through phases, without medical interventions whose effectiveness has not been proven,” he said.

Goepferd emphasizes that the gender health program is not like a tunnel that one enters as a boy and exits as a girl – or vice versa. Every patient is different and there is room for this diversity.

“The agenda is set by children and families, not by us,” they explain. “They may or may not end up taking medication, they may or may not transition socially, they may or may not change their identity over time – my only goal is to help them thrive.”

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Care is said to be slow, thoughtful and multidisciplinary. “We work with our speech therapy rehabilitation team; we work with our psychiatry team, with medication management. We provide nursing care that helps families manage appointments, resources and those kinds of things.

With all the political attention being paid to transgender children right now, Goepferd also spent a lot of time recently in the Minnesota State House as laws affecting their patients were passed. “Sometimes it takes a pediatrician to speak up and correct misinformation,” they say. “I’ve had some disingenuous questions from legislators, but I’ve also had some very sincere questions from legislators who were just trying to understand. »

This very public work came at a personal cost. Goepferd claims they received death threats. But they don’t plan to stop.

“If I can’t disseminate accurate information and if I can’t help create the cultural change that trans kids need, the medical care I provide simply won’t make a difference,” says Goepferd.

After all, they say, most of what affects a child’s well-being happens outside the doctor’s office.

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