Three years ago, when Marshall was 13 years old, he asked his mom if she would buy him a binder for his upcoming seventh grade graduation. She asked what he needed—three-ring? pockets? any specific color?—but couldn’t figure out exactly what he was describing. Finally, he sent her a link to the binder he wanted. It was a chest binder. He was trying to come out as transgender.
Marshall’s mother, Laura, took the whole thing in stride. She started addressing him with male pronouns and made him an appointment with a counselor so he had someone to talk with about his gender dysphoria. She bought him the binder to wear to his graduation ceremony. He wore it underneath a navy blue suit.
His friends were also supportive, as was his high school in Athens, Georgia. Administrators said he could use whichever bathroom he preferred, and his teachers were instructed not to deadname him.
I met Marshall, a soft-spoken teenager with a mop of brown hair that perpetually flops into his eyes, in February 2020 for his very first transition-related doctor appointment. His parents had driven him two hours to the private clinic Queer Med, the brainchild of Dr. Izzy Lowell, a 41-year-old family medicine doctor who has spent the past six years championing trans health care in the South. Marshall found the clinic thanks to a referral from his counselor, who had given him two recommendations. The other, which specialized in pediatrics, had a months-long waitlist. Though Lowell primarily treats transgender adults, about 13 percent of the practice’s patients are kids or teens, like Marshall. He was able to get a testosterone consultation within a week or two.
At the appointment, it had been nearly two years since Marshall had come out to his parents and more than three since he realized something about his body wasn’t right. “I was looking at myself one day and it felt like I couldn’t really recognize who I was looking at,” Marshall told a Queer Med nurse practitioner named Luke Scarborough. “I spent the next couple months questioning and trying to learn more about different gender identities. Then I spent a couple of years—a year or so—just trying to figure out names and how I wanted people to see me.”
What Marshall described was the very beginning of his “social transition,” a time when trans people—especially trans kids—begin living openly as the gender they identify with but have yet to start any medical interventions. (Not all trans people medically transition, for a variety of reasons.) He first started by asking a few close friends to call him by his new name and eventually built up to changing his name on a playbill for a local theater production he was in.
It was a slow process, which reassured Marshall’s parents. “Marshall really is a smart kid who thinks about things—he’s very thoughtful, not impulsive,” Laura said at the appointment. “You know, saves his money, spends it carefully, plans for the future. I trust that he is making the best decision for himself.”
During Marshall’s consultation, Scarborough went through the ins and outs of what testosterone does and doesn’t do to a young body. It does: permanently thicken your vocal cords, lowering your voice; stimulate body hair growth; redistribute body fat and make it easier to put on muscle mass; mildly increase red blood cells and liver enzymes. It doesn’t: sterilize you—testosterone is not a substitute for birth control, and trans men who want to have children can typically conceive (assuming there are no other, underlying fertility issues) within a few months of going off T.
Marshall mostly sat quietly between his parents, listening, looking at his hands in his lap. When he did speak, he whispered, his voice shaky. He only smiled once, when Scarborough, a trans man himself, started guessing what color beard Marshall would grow.
By most metrics, Marshall is one of the lucky ones: a kid who saw the kind of life he wanted for himself and, with the help of his family and compassionate doctors, is making it a reality. But even with all the right support and resources, transitioning—especially for a kid in the South—can be like building a house of cards. All it takes is a bit of wind and the whole thing is at risk of tumbling down.
In Marshall’s case, the gust is a conservative lawmaker keen on “preserving a way of life.”
In February, for the second year in a row, Georgia state Rep. Ginny Ehrhart proposed a bill that would make gender-affirming care for minors illegal. This week, a procedural rule killed the proposal’s chance of passing this year, but Lowell and her patients at Queer Med still aren’t in the clear. Over the last three years, Republican legislators across the country have pivoted away from calling trans kids predators for using the bathroom of their choice to a new fear-based campaign. Rather than going after queer people overtly, “family values” conservatives are now targeting trans kids by going after their closest allies. This year alone, legislation like Ehrhart’s has popped up in at least 17 other statehouses across the country, more than half of which are in the South. In Alabama, where Lowell also practices, a similar bill is quickly progressing. If passed, Lowell could lose her medical license and face felony charges with up to 10 years in prison.
Gillian Branstetter, media manager for the National Women’s Law Center, says politicizing trans health care is not only bad for doctors—it could tear families apart. “You’re talking about parents who are scared, who want to do right by their kid, but are now being told, ‘Don’t listen to your doctor, listen to this Facebook post you saw, listen to the state senator you’ve never heard of.’ It’s a wedge issue not necessarily because it’s going to drive people away from one party or another. It’s going to drive a wedge between parents and their kids.”
Even Marshall, who has full family support, worries about the damage these bills could do. “For me and other trans kids,” he says, “it’s much more abusive to allow [us] to keep living in pain.”
Data on trans-inclusive health is scant, in part because of how rare it can be: An estimated 30 percent of trans people have postponed or avoided going to the doctor for fear of discrimination. National Center for Transgender Equality surveys have found that about half of trans people have had to teach their doctors how to care for them. In one survey, 28 percent of respondents said they’d been harassed in a medical setting, and another 19 percent said they’d been refused service, even for procedures that had nothing to do with their gender identity.
Facing this landscape, in the early 2010s, Lowell created her own elective to practice gender-affirming care as a medical resident in Massachusetts and trained at the Mazzoni Center, a longstanding LGBTQ-focused medical practice in Philadelphia. In 2013, she landed at Emory University’s Family Medicine Department in Atlanta. Health care access was imperfect for the folks she served in the northeast, but still, she was shocked by how much worse it was down South.
In 2015, she pitched the idea of a family medicine clinic that catered to transgender patients, but the university’s administration was skeptical. She offered to do the work unpaid until the clinic turned a profit. “They were like, sure, but there aren’t any transgender people in Atlanta,” Lowell remembers. (Emory declined to comment for this story.)
“There’s hubs like Boston, San Francisco, Philadelphia, LA, that have great gender centers,” Lowell says. “And so everybody’s like, ‘Oh, just go to one of those.’ But this is as common as Type 1 diabetes. And you would never tell a diabetic, ‘Just go to San Francisco every three months—they’ll take really good care of you. You’re all set.’”
Despite the university’s initial resistance, the clinic filled up quickly, Lowell says, and turned into one of the most profitable teaching clinics at Emory. It also had the lowest no-show rate, despite the fact that many of her patients came from outside the Atlanta area. “This one patient stands out in my mind,” Lowell says. “It was right before lunch and my patient was late—it was cutting into my lunch hour.” When he got there, he apologized profusely, explaining that he’d driven more than five hours from central Tennessee for this appointment. “And I was like, okay, that’s a legitimate reason to be 15 minutes late for your appointment. It just kind of put everything into perspective.”
In 2017, Lowell left Emory and opened Queer Med with the goal of giving trans people more flexibility. Rather than making patients trek hours to see her, she wanted to bring the hormones and puberty blockers to them. Lowell borrowed some office space from a local therapist, but the location didn’t really matter. She got licensed in four other states—Alabama, North Carolina, South Carolina, and Tennessee—and conducted most of her appointments via video call. But testosterone is a Schedule III drug, so she had to do all of her primary consultations with trans men in person. She crisscrossed Georgia in her Subaru to make house calls on some patients; others came to her at out-of-state pop-up events at community centers and the occasional church. Within two years, Lowell had more than 1,000 patients. Her practice grew so popular that she moved to a dedicated office space in Decatur, Georgia, and got additional licenses in Florida, Kentucky, Maine, Mississippi, Virginia, and West Virginia.
“She’s really, in a lot of ways, single-handedly transforming what the landscape looks like for trans folks in the South,” says Ivy Hill, the community health program director for the Campaign for Southern Equality, who met Lowell in 2019 when Lowell came to see patients at an annual summer camp for transgender people. “I think that telemedicine just does by its very nature remove a lot of the barriers that our folks have in accessing care, but then she’s gone the extra length to get licensed in extra states. She is going to do everything she can to remove barriers for people, even if that means showing up at trans summer camp and being in a room without any air conditioning and just, like, writing letters for everybody to change their gender markers and start” hormone therapy.
Lowell’s day-to-day looks a bit different now. Because of the pandemic, the Drug Enforcement Administration waived the requirement for an in-person evaluation before being prescribed testosterone, so all of Queer Med’s appointments happen remotely. Pop-up events have temporarily stopped, but she’s still gained another 1,000 patients in the past year.
Queer Med sees patients as young as 7 years old. The practice’s youngest patients have only socially transitioned, and come by once a year or so to check in. Twelve-year-old Lily started coming to Queer Med about three years ago, mostly to build rapport with her provider and keep tabs on her development so they know when to start medical intervention. Prepubescent patients who are still exploring their gender identity often take puberty blockers, a completely reversible treatment that does just what the name suggests. The idea is that it buys kids time to explore their gender identity before their body starts to change in ways that may exacerbate their gender dysphoria. The American Academy of Pediatrics, the Endocrine Society, the American College of Obstetricians and Gynecologists, and the American Psychological Association all endorse puberty blockers and hormone therapy as safe treatment options for minors experiencing gender dysphoria.
Dr. Izzy Lowell meets with Taylor, a 15-year old trans patient, during a virtual visit in her office.
Elijah Nouvelage
“I feel different,” Lily told me after six months on blockers. “In my dreams, I see myself different—like what I look like.” Her hair is longer, like she’s always wanted.
For kids who decide to move forward with hormone replacement therapy or, like Marshall, have already started puberty, Queer Med prescribes a low dose of testosterone or estrogen, which is slowly ramped up over a year or two.
Though the long-term effects of hormone therapy are unclear—some studies suggest it could lead to a decrease in bone density or increased cardiovascular risk—most experts say the benefits outweigh the risks. As Dr. Jack Turban, a child and adolescent psychiatry fellow at Stanford, wrote in a 2018 Vox op-ed: “Every decision in medicine involves weighing risks and benefits. Lipitor, a medicine doctors use to prevent stroke, also increases the risk of rhabdomyolysis, a condition of muscle breakdown that can damage the kidneys. However, the potential benefit of preventing stroke far outweighs the potential risk of this unlikely event. The same is true for transgender youth and gender-affirming care.”
When I asked Dr. Madeline Deutsch, director of the University of California, San Francisco’s Transgender Care clinic, about the medical professionals who dispute the safety of hormone therapy for minors, she replied simply, “Yeah, and 1 percent of scientists believe that climate change is a hoax.”
Lowell also tries not to dwell on the fringe physicians or the political narrative. She doesn’t read the news; she doesn’t own a television. She’s a stoic, keep-your-head-down-and-do-the-work type, primarily focused on making sure her patients have the information and tools they need to feel better.
That singular attention continues to lead her far beyond the confines of her office. When I visited Queer Med last year, Lowell and I were exchanging niceties in the lobby between appointments, while Marshall was rushing back to Athens, hoping to get to the lab for a blood test before it closed. A nurse poked her head out from an office: A patient had called, saying he didn’t think he could make his appointment that afternoon; a suspicious package had been found outside an office building a few blocks away from the clinic, and parts of downtown had been evacuated and cordoned off.
“Does he want a ride? I’ll go pick him up,” Lowell offered. “Just text me an address. Tell him we’ll be there, we’ll make an effort. Expect us in about 15 minutes.”
“This doesn’t normally happen,” she assured me before heading out the door.
This legislative battle over health care for trans kids is the culmination of decades of “family values” messaging from the GOP. It combines the right wing’s obsession with policing uteruses and the bogus, offensive stereotype that queer people and their allies are up to some dark agenda involving pedophilia and indoctrination. The modern attacks on trans children are essentially a rhetorical spear that conservative strategists have sharpened over time.
The anti–trans health bills are most directly descended from the trans bathroom panic of the last decade, in which conservatives used the completely hypothetical threat of predatory men in dresses lurking around women’s restrooms to galvanize the Republican base. Over several years, at least 21 states considered bills banning transgender people from public restrooms corresponding to their gender identity. North Carolina led the charge and faced intense backlash that likely cost the state billions in business revenue.
Eventually, the bathroom effort was largely dropped, but by 2018, conservatives had started directing their trans panic toward a new cause. Two states—New Hampshire and Pennsylvania—took up bills that sought to limit or outright ban gender-affirming health care for trans kids. Neither passed. In 2019, two more states made the effort.
“Young people are not old enough to make these sorts of permanent, life-altering decisions,” said Illinois state Rep. Tom Morrison of his 2019 proposal. He told a local NPR affiliate at the time that minors shouldn’t be given the choice to become “permanently sterile.” Critics called the bill “reprehensible” and “based on personal objections and beliefs and junk science.”
That year, this new version of the trans panic became a rallying cry on the right, and conservatives latched onto another strategy: punish the parents. In December, two parents in Texas were fighting for custody of their kid, who, according to reports, had been identifying as a girl for years. The child’s father claimed that the girl’s mother was forcing her to transition in some sort of elaborate scheme to revoke his parental rights. A local news website run by a former Republican state senator covered the story, which was then picked up by the Daily Caller. Then Fox News pundits joined in, warning of “chemical castration,” even though the child was only socially transitioning. Soon, the story had been tweeted out by Donald Trump Jr.
Shortly after, Texas state Rep. Steve Toth vowed to introduce a bill barring minors from receiving transition-related care by redefining it as child abuse. Texas state Rep. Matt Krause made a similar pledge. Both made good on their promises. Fourteen other states followed suit with bills banning trans health care for minors, including Ehrhart in Georgia, who was reportedly motivated by the Texas custody battle. The flurry has only continued this year, with lawmakers in at least 18 states introducing so-called Vulnerable Child Protection bills, four of which include provisions that could be used to investigate and punish parents. Lowell works in seven of those states: Alabama, Florida, Georgia, Kentucky, Mississippi, Tennessee, and West Virginia.
Dr. Izzy Lowell in her office during a meeting with a patient.
Elijah Nouvelage
The lawmakers who support these proposals tend to go heavy on the theatrics and disinformation. Last year, a state representative in South Dakota compared doctors who offer gender-affirming care to Nazis. Another likened such care to lobotomies. Alabama’s bill describes puberty blockers and HRT as “dangerous and uncontrolled human medical experimentation that may result in grave and irreversible consequences.”
“The way that these laws are sensationalizing this experience is really putting a focus on an issue that doesn’t exist,” says Jen Bennett, a licensed professional counselor in Charleston, South Carolina, who often refers transgender adolescent patients to Lowell. “These services are really, really, really difficult to obtain in the first place. And secondly, they are, in every single way, validated—ethically, morally, empirically, scientifically—as the right choice. And by the right choice, I mean, if it’s chosen by the person who’s transitioning, and it is chosen by their parents, those are the people making that decision. And if it is also chosen by a doctor, that [decision] is going through three very, very concerned and interested parties about whether this is the best choice for this person.”
For all the dog-whistling surrounding them, legal experts say that, like the bathroom bills, this new wave of legislation likely won’t get very far. Public opinion is steadily shifting in favor of treating trans people like, well, human beings, and the Supreme Court affirmed last year that prohibitions against sex-based discrimination also includes trans folks. The Biden administration has vowed to enforce the ruling.
“These types of measures have the same fatal flaws as the previous measures that failed,” says Alex Rate, the legal director of the ACLU of Montana, which has already fended off one anti-trans health care bill this year, although another watered-down version is now pending. “You’re talking about measures that are incredibly invasive, incredibly debasing to human dignity and privacy, and which are facially discriminatory on the basis of sex.”
And yet, these proposals aren’t exactly designed to succeed. As Andrew Reynolds, a political science professor at the University of North Carolina, Chapel Hill, told me when these bills popped up last year, gender identity is one of the last cultural wedge issues conservatives can rely on. “It’s the only lever, I would say, that still can drive conservative, religious, white voters—fearful voters—to Republicans.”
Nevertheless, the result is a target on the back of trans kids, their families, and their doctors. David Fuller, a police sergeant from Gadsden, Alabama, took a full day off work in February to ask lawmakers not to pass an anti-trans health care bill. Fuller’s now-adult daughter came out to him at age 16 and, after nearly a year of talk therapy and consultations, received transition-related medical care at the University of Alabama at Birmingham.
“I was probably like you guys,” Fuller told Alabama House Judiciary Committee members. “I didn’t like this, I didn’t understand it, I was ignorant to it. But I was a police investigator for a long time, so I put myself to the grindstone and started investigating. Unfortunately, the first thing I found was that half the kids, the teens that are transgender, try to kill themselves. I was terrified. But after a little more looking, I found out that number drops to just below normal for kids their age if they’ve got cooperation from their family, health care, and therapists.”
Fuller described his daughter’s doctors as “angels” and begged the lawmakers, “You’re asking me to someday put handcuffs on these people that are heroes in my life and arrest the people that saved my daughter? Please don’t ask me to do that.”
The Alabama bill is still being considered by the House Judiciary Committee; a nearly identical proposal passed the Senate and is being considered by a different House committee.
“It’s an attack on doctors and science, and a direct shot at trans youth—some of the most vulnerable folks who are trans,” says Hill from the Campaign for Southern Equality. “It worries me for them in terms of their actual access to care. But it also worries me for them when I think about trans youth suicide rates.” The evidence bears out Hill’s concerns: Trans Lifeline, America’s first helpline established specifically for transgender folks, for example, saw average daily calls double the week the Trump administration rolled back Obama-era protections allowing trans kids to use the bathroom of their choosing. A recent survey by the Trevor Project found that more than90 percent of respondents (all LGBTQ youth) said that recent politics had negatively influenced their wellbeing. “I think about the messages that this sends to them about who they are, and there being something wrong with just who they innately are and the shame that comes with that.”
The bills make Lowell nervous, too: Some of them would make her a felon and bar her from practicing medicine. “It’s something that I worry about a lot,” she told me recently. “But I think that I’m too far in it. If they want to put me in jail, they probably could based on everything that I’ve already done. And if we say, ‘Okay, we’ll get out of Alabama,’ they’re going to come after Georgia, Mississippi, and half the other states we serve.”
Similarly, Marshall and his family said they worry about such bills but have never considered postponing his transition. “I have no doubt that I would find a way to get whatever he needed,” said Laura, Marshall’s mother. She said without hesitation that her family would cross state lines to fill his prescriptions, and even consider leaving Georgia permanently. “We would go to whatever state we needed to. I’m not afraid to break the law.”
When I checked in with Marshall in late November, after nine months on testosterone and a successful legal name change, he didn’t necessarily sound like a new person. He just sounded like the person he was supposed to be all along.
His voice was an octave deeper and, more noticeably, it was loud. “I’ve been feeling a lot better to be honest,” he said. “Back in January, February, for a variety of reasons, I was getting close to being depressed. I was anxious a lot of the time and just overwhelmed. And I guess partially because of transition and partially because of the pandemic and not having to go to in-person school anymore, I’ve been able to take a step back and feel better about myself.”
Lowell and her team told me that emotional turnarounds are common, often showing up even before the physical manifestations of hormone therapy. For every kid I met at Queer Med like Marshall—a fragile first-timer—I met two or three who had been seeing Lowell for years and were absolutely exuberant.
“I’m not shy about sharing my story,” Marshall says. “It’s been helpful to me to see other trans people be able to live their lives confidently and bravely, and part of me wants someone else to see that there are other kids out there, to give them some sort of hope.”
Hormones don’t fix everything, Lowell says, but the “gender dysphoria, seeing that just evaporate is the coolest thing.”
“The times that I’m most reminded how much this is needed are families that come in with the kid, having wanted this for years, begging their parents who are very much against it. And then over time, the parents come to see how much it’s harming the kid to withhold therapy,” Lowell explained. “So they arrive here, still sort of against it, but not sure. And then we meet for an hour and talk through everything. By the end of it, the kid is practically in tears, because they’re going to get to do this thing that they thought was unattainable. And the parents are so relieved, just hearing the medical risks of hormone therapy, what it’s going to do, what it’s not going to do, how long it’s going to take, what the side effects are, and the medical risks.
“The whole thing just gets less scary,” Lowell said. “Everybody walks out feeling a ton better, and I get to have changed somebody’s life.”
