Who should decide what treatments are available for children younger than 19? Should we criminalize doctors for providing treatments accepted in many other states and countries? When should government be able to creep into the treatment room with a doctor and patient?

These are some of the questions coming to a head in the debate over Senate Bill 5, the Vulnerable Child Protection Act, sponsored by State Sen. Shay Shelnutt (R-Trussville). The bill, as written, “would prohibit the performance of a medical procedure or the prescription or issuance of medication, upon or to a minor child, that is intended to alter the appearance of the minor child's gender or delay puberty, with certain exceptions., which seeks to limit gender transition treatment options to minors (defined as younger than 19).”

In response to a substantial jump in the number of children who identify as gender-fluid, multiple states across the country are debating laws to limit the ability of doctors to prescribe hormone treatments and puberty blockers to minors.

Craig Monger: Transgender questions need answering before sacrificing the next generation

Opposition to the use of these treatments in minors is often conflated as some larger bias against the LGBTQ community - Florida’s recent bill being a good example. The Florida bill is designed to limit how the LGBTQ community is discussed in public school classrooms by restricting conversations, considered “instruction,” particularly related to the youngest elementary children.

However, a bill similar to Alabama’s passed the Republican legislature in Arkansas last year. That bill, known as the Save Adolescents From Experimentation (SAFE) Act or Act 626, would ban gender-affirming medical procedures for transgender people under 18. However, it was vetoed by Republican Governor Asa Hutchinson, who appealed to his conservative principles while explaining his veto in an editorial published in the Washington Post.

“I vetoed this bill because it creates new standards of legislative interference with physicians and parents as they deal with some of the most complex and sensitive matters concerning our youths,” wrote Hutchinson.

According to the Williams Institute at the UCLA School of Law, 21 states introduced similar bills last year.  

The issue is wrought with emotion, and a considerable amount of misinformation, so it is important to understand the nuances in the debate, particularly here in Alabama.

1819 News spoke to two prominent physicians who have been advocating opposite sides of the bill.

Dr. Morissa Ladinsky, MD, Associate Professor of Pediatrics at the University of Alabama-Birmingham, is one of the few providers in the state who would be affected by the legislation. According to the law, as written, she could face a class C felony for continuing to treat her patients.

“If the bill were to become law, it would potentially charge only the physicians in Alabama who prescribe two types of medication known as blockers, medication that puts a temporary pause on puberty, and hormone therapy for older teens,” Ladinsky said. “There are just probably three of us in the state who do that work.”

Ladinsky expressed concern over having to cease treatments that are working or risk criminal charges.

“Do I violate the ethics that underscore my profession,” Ladinsky said, “Or do I risk a felony conviction?”

SEE ALSO: Transgender Life: 2 adults weigh in on Alabama bill to ban juvenile sex reassignment

1819 News also spoke to Dr. Patrick Lappert, MD, who testified before the state Senate in February advocating in favor of SB5.

Lappert was quick to point out this bill does not impede the rights of adults to seek transition therapy, only to protect children from making decisions that could affect their health for the rest of their lives.

“That’s what this legislation is about,” Lappert said. “It’s not about transgender adults, it’s about cross-sex self-identification in children.”

But are these attempts to limit the ability of children to undergo such a serious surgery born out of some oppressive impulse? Or are they a responsible limitation on an emerging area of “science?”

“It’s a classic example of what I call a political or a culture wedge issue,” said Ladinsky.

Lappert says the issue “has changed a lot in the last 10 years” and that the science, which critics claim is settled, is far from it.

“Historically, it was .02% of the entire population who experienced this,” Lappert said. “Virtually all were boys and virtually all got over it before young adulthood.

“Why have we seen a 5,000% increase in the diagnosis in the last six years? Five thousand percent! Virtually all of it is affecting adolescent girls and young adult women. Why is that?

“They haven’t presented a shred of scientific evidence explaining why this demographic shift. Yet they claim that they understand who should get life-altering medicine and surgery.”

Lappert cited the lack of diagnostic procedures and standards for evaluation as further evidence this treatment should not be allowed before adulthood.

“They don’t have a diagnostic process,” Lappert said. “They have a questionnaire. That is the criterion for treatment. They have no objective test. It’s all subjective and it’s all self-identification by a child.”

Ladinsky strongly refuted that claim and explained the process involves a team of doctors from multiple specialties who evaluate these cases for anywhere from six months to three years before allowing patients to begin puberty blockers or hormone treatments.

The mental health component is inextricably linked to this issue, as Ladinsky highlighted in her explanation for a multi-disciplinary approach to treatment.

Lappert expanded on the correlations in biological females with mental health struggles.

“If you take adolescent females who experience cross-sex self-identification, they have greater than a 40% likelihood of being clinically depressed or suffering from a major anxiety disorder, yet these clinics are claiming that these children should be able to make decisions for themselves,” said Lappert.

As for the notion of children making these decisions themselves, Ladinsky was adamant that these procedures are never attempted without parental consent.

An international group of experts focused on transgender health last month released a draft of proposed updated guidelines for the treatment of adults, urging a more cautious stance on teens. The draft guidelines include a chapter dedicated to adolescents, which says that they must undergo mental health assessments and must have questioned their gender identity for “several years” before receiving drugs or surgeries. 

What about children in the foster care system or children estranged from their parents?

According to Ladinsky, their policies would not allow it, nor would their insurance carriers.  

1819 News asked Ladinsky to respond to people who do not wish to discriminate against anyone in the LGBTQ community, but who have concerns about these treatments on children. 

“This group - they are a small and a very nuanced population of kids,” Ladinsky said. “The medicine and the affirmation they deserve is also very nuanced and delivered by a team of sub-specialty doctors who have trained and practiced for a very long time.”

The primary concern for both sides appears to be the well-being of vulnerable children dealing with very personal, confusing issues. Just as one side can advocate the benefits of care, the other can reasonably cite the perils.

Ladinsky closed by appealing to the conservative principles Hutchinson used in his editorial.

“Governments under a conservative philosophy highly value limited government and individual rights,” Ladinsky said. “The state is given police power in the name of upholding public safety. Does this warrant the police power of the state legislature of Alabama? I would contend absolutely not. This is vast government overreach into the space where parents and doctors work together.”

On the other side, there are those who say this is exactly where government is meant to step in to avoid vulnerable populations making decisions they may regret.

“We’re starting to see young adults coming to the realization that ‘This is not a good thing I did to myself; this is not a good thing I was convinced that would help me and I can’t believe the doctors let me do this,’” said Lappert.

Striking the balance between empowerment and protection remains the challenge faced by sincere parties on both sides of this issue.

To connect with the author of this story, or to comment, email news@1819news.com