Transgender youth in North Carolina may soon have fewer options for care. State lawmakers are considering a bill that would ban doctors from giving puberty blockers, cross-sex hormones and transition surgeries to anyone under 18.
Another bill would ban public health providers from doing the same.
Youth currently taking blockers or hormones would be allowed be continue, but some say the proposed legislation could have consequences for their younger peers.
Sean Radek, of Charlotte, is one of them. He was 16 when he underwent top surgery to remove his breast tissue. If you ask him if the decision was rushed, he smiles and shakes his head no.
"I think a lot of the lawmakers right now think that you can just walk into any plastic surgery place and be like, "Give me this surgery,' and they'll be like, 'OK, let's do it tomorrow!'
"But it was definitely a harder process than that," he said.
Radek, now 17, said the process actually took years. It involved lengthy evaluations and conversations with his therapist, his doctors and his mom.
Insurance wouldn't cover the surgery before he turned 18, so he crowdfunded. It cost about $10,000.
Radek said he always knew it was what he needed.
"It was so difficult waking up, looking in the mirror and seeing something that I don't feel like should have belonged there," he said.
Radek had come out as trans five years earlier, and said his mental health wasn't great. For three years he bound his breasts. And for two years, he took hormones.
Now, a year and a half after surgery, he says he had no regrets.
"I think it's one of the best decisions I've made in my life, and I'm super happy about it, because it feels like me," he said.
About 1% of North Carolina teens identify as transgender
Radek is one of an estimated 8,500 transgender youth in North Carolina — or about 1% of teenagers in the state, according to the UCLA Williams Institute.
The number is roughly double what it was in 2017 — in line with a national rise in transgender youth.
Even though the number of trans kids is small, gender care has become an emotional and potent political issue.
And it has pit trans teens, their parents and their doctors — who say treatment is essential and lifesaving — against lawmakers and activists who assert there’s not enough research into the efficacy and possible long-term side effects. Opponents also say treatment is too readily available.
Burke County Republican Hugh Blackwell, one of the sponsors of the North Carolina bill to ban youth gender care, addressed the issue of transition surgeries at a committee meeting in May.
"If you are under the age of 18 in North Carolina, you can't get a tattoo at all, even with your parents' consent. You can't get a body piercing, other than for earrings, without parental consent. But we allow these surgical procedures that, in many instances, maybe are irreversible and life-changing for children who have not arrived at 18 years of age," he said.
WFAE reached out to Blackwell and other bill sponsors, but none made themselves available for interviews.
Puberty blockers, surgeries are rare among trans youth
In North Carolina, only a tiny fraction of trans teens have transition surgeries, according to Dr. Deanna Adkins of the Duke Center for Child and Adolescent Gender Care.
"I would say maybe five a year," she said.
Most major hospitals, including Atrium Health, Novant Health, UNC Health, ECU Health and Duke Health, don't offer the surgeries to minors. Only a few private practice surgeons do.
Adkins said teenagers are only referred for surgeries if they've taken hormones for at least a year, can give informed consent, and have written support from their therapist, pediatrician and parents.
Teens also need to be in "a good place, and a good time and healthy enough to move ahead," she said.
Puberty blockers are also rare in Adkins' clinic. Only about 2% of her patients take them — and never before a child has begun puberty.
Adkins also requires all patients to undergo a mental health evaluation and extensive testing before receiving any kind of treatment to make sure their body can receive the treatment, "and to make sure that they don't have something else going on medically or psychologically that might be either causing their complaints or symptoms, or impeding their ability to access and complete care."
Long-term 'unknowns,' side effects, regret among some lawmakers' fears
Multiple studies suggest puberty blockers, hormones and surgeries can improve mental health and body image for transgender youth, but long-term research is in its infancy, and protocols for treatment can vary from practice to practice.
Conservative lawmakers and activists say those long-term unknowns and the possibility of harmful side effects can't be overlooked, and some opponents say there's a risk adolescents could get treatments they later regret.
Lawmakers heard from one woman, Prisha Mosely, who said at a hearing last week she wished she hadn't taken hormones and underwent surgery when she was younger.
"At 17, after meeting with me for a matter of minutes, a counselor told me that I was actually a boy, and that changing my body to be more like a boy's would fix my mental health issues," she said. "Around this same time, a pediatric endocrinologist prescribed me testosterone."
Then living in Greensboro, Mosely said she was suffering from depression, borderline personality disorder, an eating disorder and trauma from a sexual assault.
Now in her 20s, she said her discomfort with her body was misinterpreted as gender dysphoria, but she and her parents felt pressured by doctors to go along with treatments. She underwent breast-removal surgery at 18.
"As a result of these healthcare providers' actions, I have suffered severe and lasting injuries. These injuries are both psychological and physical in nature. My body did not develop the way it should have, and does not function normally," she said.
Conservative lawmakers also point to western Europe, where a similar debate is playing out — though not along the same "left-right" ideological lines.
The U.K., Finland, and Sweden have limited some treatments for transgender minors to clinical settings, saying more research is needed. Health officials in Norway and France have also urged more caution.
Major medical organizations in the U.S continue to support gender care for minors, including the American Academy of Pediatrics, and the American Medical Association, which recently reaffirmed its position.
'If I didn't get that surgery when I did, I don't think I'd be here'
A trans teen named Felix leans back on the sofa in his home in Concord, North Carolina, and squeezes his eyes shut as his dad guides a small needle toward his stomach.
"You ready?" his dad asks. "It's just a small poke."
Felix, is a few weeks shy of turning 15 and of undergoing breast-removal surgery. This is his weekly hormone shot. WFAE agreed not to use Felix's or his parents' last name to protect their privacy.
His father, Tim, said the family had carefully considered each step of treatment, and they were aware of possible side effects, such as infertility, that can come from long-term use of hormones.
But he saw it as a tradeoff for his son's mental health.
"Chemotherapy has some really rough side effects and you get really sick, but it's probably better than dying from cancer," Tim said.
"I think hormone therapy, even if it has some side effects that you don't love — and frankly, at this point, I think we love them — but even if it had some negative side effects, that's probably better than dying from suicide," he added
Felix says he thinks lawmakers' efforts to ban treatments are going overboard.
"I think it's so hard to access it already, you don't need to make it impossible," he said.
Sean Radek — the 17-year-old who had breast-removal surgery when he was 16, said for him, hormones and surgery worked out as a positive. He's now preparing for his senior year of high school and looking at colleges where he might study architecture. He said surgery may have saved his life.
"If I didn't get that surgery when I did, I don't think I would be here," he said.
He worries that waiting until 18 to start treatment might not be an option for a lot of transgender youth, and is concerned about the negative impact the proposed North Carolina legislation could have on them.
"Two years is a lot of time. Three years is a lot of time, and some (trans teens) may not make it that far," Radek said.
He said that such a dire outcome is one that he hopes no one wants.
