Brian Lehrer: Brian Lehrer on WNYC. NYU's hospital system is caught between local and national politics right now. The Trump administration says no more gender-affirming care for minors, or they'll cut off federal funding. The state of New York says NYU is required to offer that care. We will discuss now with a couple of guests. First, just on what's going on with NYU in this political vice, we have Giulia Heyward, Day-Of reporter here at WNYC and Gothamist. After her, we'll hear from Dr. Jack Turban, adult, child, and adolescent psychiatrist, and author of the book, Free to Be: Understanding Kids & Gender Identity, on what this moment means for the patients caught in the middle. Hey, Giulia, welcome back to the show.

Giulia Heyward: Hey, thanks for having me.

Brian Lehrer: How did NYU Langone explain its decision to close its transgender youth health program? Because they were doing this.

Giulia Heyward: Yes. Okay, so the families that we spoke to said that NYU told them directly. When we reached out to the hospital ourselves, they confirmed this. A spokesperson for the hospital said that they were ending the program because of the current regulatory department. Basically, the Trump administration has been trying to penalize hospitals that offer gender-affirming care to children and teens for a while.

Brian Lehrer: Right. The current regulatory environment was their quote. On February 25th, as Gothamist and other outlets reported, attorney general for New York State, Letitia James, published a letter ordering NYU Langone to reinstate the program within 10 days. That deadline was March 11th. What's her legal argument for why the hospital has to comply with the state rather than the federal government?

Giulia Heyward: That is a great question. Basically, hospitals right now, the ones that have been shuttering gender-affirming care for children and teens, are doing so to get ahead of a proposal from the Trump administration. The Trump administration is proposing stopping hospitals that perform gender-affirming care treatments on minors from receiving Medicare or Medicaid funding. This is a lot of money.

What some hospitals are doing is just getting rid of the practice altogether in order to be in compliance ahead of time. What the attorney general's office is arguing is that in New York, we have something called our human rights law. Basically, it prohibits discrimination against one's gender identity, which is what this would fall under. By denying some patients access to gender-affirming care, you are discriminating against their gender identity.

Brian Lehrer: Do you happen to know why Attorney General James went after NYU Langone but not Mount Sinai, which I think has also maybe more quietly stopped providing gender-affirming care to adolescents? I guess concerned about the federal threat of a funding cutoff to them and maybe even other hospitals. Do you happen to know if the attorney general is singling out NYU Langone or if this is a broader order?

Giulia Heyward: That is a really good question. To be so honest with you, we don't actually know. We do know that NYU was one of the first hospital systems to come out and say what they were doing. In the case of Mount Sinai, we reached out to them multiple times. They were not able to confirm that they were ending this gender-affirming care. We were able to report on that story from having talked to parents and families that were affected by this decision. Many of whom spoke to us anonymously because they were afraid of retribution.

Brian Lehrer: How will this get resolved? You have the federal government saying, "You may not do this." You have the state government saying, "You must do this." How does this ultimately get resolved?

Giulia Heyward: That is another great question. Well, I've been reaching out to NYU, Mount Sinai, and the attorney general's office every single day, basically trying to find out what happens now. We know that the attorney general's office gave NYU the deadline of March 11th to reverse this decision. The attorney general's office didn't necessarily give an explicit answer as to what they would do next, but the letter that they sent said that they were prepared to enforce this. We could see a lengthy legal battle play out, but your guess is really as good as mine right now.

Brian Lehrer: There we leave it. Listeners, maybe now, you know a little bit about that political vice that NYU Langone and, by extension, other medical centers in New York that at least had been providing gender-affirming care to minors, that vice that they are now in. Giulia Heyward, Day-Of reporter from WNYC and Gothamist, was on it when Letitia James' aspect of the story came out. Giulia, thanks for explaining it.

Giulia Heyward: Thanks, yes.

Brian Lehrer: Now, we're going to talk to a doctor in just a second, who provides that care about emerging best practices. With us now is Dr. Jack Turban, adult, child, and adolescent psychiatrist, and author of Free to Be: Understanding Kids & Gender Identity. Dr. Turban, thanks for coming on with us again. Welcome back to WNYC.

Dr. Jack Turban: Hi, good morning. Thanks for having me.

Brian Lehrer: You're in the Bay Area of California. Are they having the same kind of pressure? Do you know? The hospital is there from the Trump administration, and is the state of California, just by way of comparison, responding the way the New York attorney general is?

Dr. Jack Turban: Certainly, these federal threats are impacting hospitals nationwide. Like you just heard, it's mostly a threat to take away federal funding. Just so people understand, it's not just federal funding for the gender-affirming care programs, but what the federal government has threatened is that they're going to take away all Medicare and Medicaid funding from any hospital that has a pediatric gender program, so, really, a financial threat that I don't think most hospitals think they could survive financially.

Another thing that's really important to know, though, is that that threat is not law. Centers for Medicare and Medicaid have proposed this rule to do that, to take away the funding, but there was a comment period. Now, the federal government is reviewing the comments, including major medical organizations that told them not to do this before the rule is final. There's no law requiring hospitals to close their clinics. Most clinics in California are still open. There have been a few that, similar to NYU, have preemptively closed their clinics due to fear of what the federal government might do.

Brian Lehrer: This, at least for people under 19, is becoming less available. I wonder, as a psychiatrist who works with families that do have people under 19 who are seeking one kind or another of gender-affirming care, how you make the decisions, how you advise them, and help them make the decisions that are obviously very fraught and very complicated for any individual, for any family.

Hormone therapy, surgeries can be difficult or impossible to reverse or, to some degree, difficult or impossible to do it once they're past a certain age, so how do you and your colleagues assess whether a young person is really going to benefit, or how the risk-benefit calculus is made for an intervention like that dealing with an individual and an individual family?

Dr. Jack Turban: To your point, these are big decisions to start these medical interventions. Doctors in this area follow two sets of guidelines. There's the Endocrine Society guidelines and also guidelines from this organization called WPATH, or the World Professional Association for Transgender Health. That's an international organization. Both guidelines emphasize that for minors, they need to undergo a comprehensive mental health evaluation before they consider these treatments.

When we do that evaluation, we're looking for, are there any other mental health conditions this person has that need treatment or that could interfere with their ability to make a decision about this treatment? How long have they had gender dysphoria? To what degree is their gender dysphoria causing impairment? We have some patients who are so distressed by their gender dysphoria that they can't shower or they can't go to school.

We also work really closely with their families to make sure they understand all the risks, benefits, and side effects of these treatments. It's really an involved process, weighing the potential benefits of the treatment against the potential risks of treatment in the same way we do in really any area of medicine, but much more involved in terms of having a mental health assessment before starting the treatments.

Brian Lehrer: After a recent segment we did on this topic, we heard from a listener who asked to remain anonymous. They wrote us an email. A parent of two trans children, as they identified themselves. This parent wrote that their eldest, who was 24 at the time, received a hormone prescription on their very first clinical visit. Now, they weren't under 19. The adult child was 24, but still received a hormone prescription on their very first clinical visit.

The parent felt that they couldn't get a straight answer on the risks when the parent tried to research them. That listener also wrote that when their younger child came out at age 11, the parent was more hesitant to proceed as well. Well, the parent was more hesitant to proceed. That led to a Child Protective Services investigation. I guess my question for you is, what role should parental approval or support or skepticism play in the assessment process for someone under 19?

Dr. Jack Turban: For someone who's a minor, which, in most states, it would be 18. The federal government has used this 19 number, but that's atypical of how we usually think about things.

Brian Lehrer: Right.

Dr. Jack Turban: For patients who are adolescents or minors, they can't make their own medical decisions in almost any area of medicine. You need parental consent to start these treatments. Most people's practice, certainly, my practice, is that when we're going through that mental health assessment period, the parents are very heavily involved. I meet with the adolescent individually.

I also meet with the parents individually to hear their perspective on their child, make sure I understand all of their concerns, make sure they're all being addressed and considered, and then everyone really needs to be on board before starting treatment. I've not heard of any patients in this area ever having a CPS call about something like that. I would need to know a lot more details to know what happened there, but that's definitely not typical. Generally, there needs to be parental involvement and parental consent for a minor starting any of these treatments.

Brian Lehrer: We also heard from listeners after the previous segment who feel that maybe there's a tendency on the part of some to be too quick to dismiss skeptics of youth gender medicine as bigots rather than engaging with their concerns about the evidence. They point to something called the Cass Review. Maybe you can explain what that is. Also, decisions by Sweden, Finland, and the UK to restrict care to minors, which presumably are not governments being driven by a narrow religious view of gender differences or anything like that. I'm curious your reaction to that in general, but also whether you as a practitioner in this field, as stories about regrets and detransitioners hit the news, whether it's made you more cautious about recommending it for any individuals.

Dr. Jack Turban: Yes, the first thing I would say is that I don't think parents' concerns should ever be dismissed. One thing the research shows really consistently is that parents' understanding in support of their children who are transgender, that's one of the best predictors that these kids are going to do well. I want parents to come to me if they have concerns because I want to make sure that I can give them the most useful information. They might also have concerns that suggest that we shouldn't do treatment right away.

I would want to know that, right? Parents know their kids best and really need to be closely involved in the process. We do often talk about these things that you're mentioning that are understandable, things that parents are worried about, so regret or detransition are things that parents are always worried about. From the studies we have, regret appears to be pretty uncommon, maybe on the order of a few percent tops. It's very complicated.

Sometimes people stop treatment or detransition because they're so harassed for their transgender identity that they feel forced to go back into the closet. There have been other cases where people have said that their detransition was from feeling that their initial diagnosis of gender dysphoria was wrong and that they thought it was from something else. We very carefully screen for any of those conditions. We go through that literature on detransition closely to make sure that we're preventing that from happening to future patients. Sorry, it's a multi-part question you asked--

Brian Lehrer: That's okay. I'll re-ask the other part. This Cass Review, which I guess came from the National Health Service in the UK. From what I've read, it concluded that the evidence based for gender-affirming care in minors is poor, meaning they questioned some of the standards used in the publication of studies. They also recommended restricting the routine use of puberty blockers and putting their use in a research trial before going forward. Some skepticism coming from this National Health Service of the UK study. If you would characterize it any differently, feel free, but your reaction to it if that was a fair take on it.

Dr. Jack Turban: The Cass report came out, I'd say a few years ago now, and I think you're describing it accurately. It was a review of the existing literature where they talked about the studies that we had on the mental health benefits of these treatments. I think what's important to know is that they're using a very technical rating scale when they're doing these systematic reviews or assessments of the literature.

It's true that most of the research in this area is based on observational research, not randomized controlled trials. I'm going to try to not get into the weeds too much, but I think what is sometimes obscured when people talk about the Cass Review at a high-level summary or in the news is you lose the fact that there are over 20 studies in this area. They all have different strengths and weaknesses, but they all point in the same direction that these kids are getting better with treatment.

We've had these treatments since the '90s. Now, decades of clinical experience showing that these patients do quite well. There's another important difference between some of these European countries and the United States. The Cass Review, the author, Hilary Cass, a pediatrician, in that report, or maybe it was an interview after, she said, "There are undoubtedly young people who benefit from these treatments." Certainly, there are kids with gender dysphoria who benefit from gender-affirming medical interventions.

The Cass report author agrees with that. In the United Kingdom, they really want to move treatment into research settings and collect careful data. They started a puberty blocker trial. I think it's currently on hold, but they're hoping to move forward with that. They're not banning care, trying to shut down care the way a lot of states have done in the United States, but rather have reorganized their care and wanted to collect more data, pointing out that we don't have, for instance, randomized controlled trials.

Brian Lehrer: One more question. This comes from a listener who writes, "I reached out to a local New York City hospital about gender-affirming support for my trans child. I thought they would do the mental health assessment, but they said that we just needed a letter from my child's current therapist to get started." Listener writes, "I was surprised by this. How can they be sure that every outside therapist has the correct qualifications to determine whether the child is in a good place to receive this life-altering treatment?"

Dr. Jack Turban: I think probably what's happening in that situation is that hospitals have limited funding and often don't have enough money to have psychologists on their own staff to complete these assessments. There simply are just more patients than they're able to hire psychologists to do these assessments. They often do ask them to go to community providers or therapists to do this.

The WPATH guidelines and the Endocrine Society guidelines do point out that there are qualifications those therapists need to have, including having specific training in this area, as well as training in child development. Again, without knowing details of that, I presume the hospital was saying, "Find a therapist who's qualified to do this under current guidelines," which can be really difficult for families, that even in the community, there aren't a large number of therapists who are comfortable or experienced doing this.

Brian Lehrer: Yes, so the best practice conversation is complicated. As you've been reflecting, the political conversation is should the government be in the business of telling parents on a universal nationwide basis, you may not agree for this for your child under 19. In any case, that's the political conversation that the Trump administration and the state of New York are in conflict over. We're not going to resolve that here. Just we're going to note it. Dr. Jack Turban, adult, child, and adolescent psychiatrist, and author of Free to Be: Understanding Kids & Gender Identity, thanks for talking through some of the complexities with us.

Dr. Jack Turban: Thanks again for having me.

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