Gender-affirming care for minors hangs in balance as North Dakota trial begins
Daniel Shumer, a pediatric endocrinologist and clinical associate professor of pediatrics at the University of Michigan, testifies Jan. 27, 2025, for the plaintiffs during a trial on North Dakota's ban on gender-affirming care for minors. (Mary Steurer/North Dakota Monitor)
A court in Bismarck on Monday kicked off a trial to decide the fate of North Dakota's ban on gender-affirming care for minors.
The law, signed by former Gov. Doug Burgum in 2023, makes it a crime for health care professionals to provide gender-affirming treatment to anyone below age 18. The ban contains an exemption for adolescents who had been receiving treatment before it went into effect.
Over the course of the trial, anticipated to take eight days, attorneys will debate whether the law violates personal autonomy and equal protection rights under the state constitution.
The lawsuit is brought by North Dakota pediatric endocrinologist Luis Casas, who is challenging the ban on behalf of himself and his patients.
'This case is not as complicated as it may seem,' Brittany Stewart, an attorney for Gender Justice, said in her opening statement. 'All North Dakotans have a right to personal autonomy to make decisions about the health care they need or don't need to live happy, healthy lives as their authentic selves.'
Judge limits scope of lawsuit over North Dakota gender-affirming care law
Previously, the plaintiffs also included three North Dakota families with transgender children. South Central Judicial District Judge Jackson Lofgren ruled earlier this month that the families did not have standing to participate in the case because their children were receiving gender-affirming care before the law took effect, and therefore do not fall under the ban.
The families will still testify as witnesses for the plaintiffs.
Doctors and others with expertise providing care to transgender youth, including Casas, also will be called to the witness stand.
The state says the science behind gender-affirming care is not settled and that the ban is needed to protect children.
'The health care law is a constitutional regulation of practice in medicine, in the area of medical uncertainty,' Special Assistant Attorney General Joseph Quinn said in his opening statement for the state. 'This is something that the Legislature has the power to do, has the right to do and it has the responsibility to do.'
Experts called by the state will testify that the standards of care are based on emerging, low-quality evidence, Quinn said.
On Monday, one of the children of the three former plaintiff families testified about his experience receiving gender-affirming care in North Dakota. The seventh grader testified under the pseudonym James Doe to protect his identity.
Doe said that today, he lives as a typical 13-year-old. He enjoys spending time with friends, plays football and is a part of the school band.
He knew he was transgender from age 4 or 5, he said.
'I kinda felt more like a boy. I liked Legos more than Barbies, more of my friends were boys,' Doe said.
Though many of his peers accepted him as a boy in elementary school, there were ways his school did not accommodate him. He had accidents because teachers wouldn't let him use the boys restroom, for example.
After coming out to his family as transgender, he started attending therapy to help with his gender dysphoria, he said.
At age 10, Doe was referred to Casas to discuss gender-affirming treatment. He said that Casas had him wait six months to start puberty blockers.
'He made me go home to think about what I really wanted,' he said.
Doe said he started testosterone treatment at age 13. Similarly, he said Casas urged him and his family to think seriously about the treatment before pursuing it.
'It's helped me become more comfortable with myself,' Doe said of the treatment. 'Medication really makes me who I am today.'
He said he's had to travel to Moorhead, Minnesota, to receive the treatment from Casas, which has caused him to miss school, extracurriculars and time with friends.
Judge denies request to halt enforcement of transgender care law
Most of Monday morning and afternoon, the court heard from Daniel Shumer, a pediatric endocrinologist and clinical associate professor of pediatrics for the University of Michigan.
Research indicates that transgender youth who start gender-affirming treatment during the early phases of puberty are happier and healthier than those who start gender-affirming treatment after puberty or during adulthood, he testified.
The way puberty affects the body is significant and irreversible, so being forced to undergo puberty in a way that clashes with their gender identity can be devastating to transgender adolescents, Shumer said.
'It may be nice to say that these are decisions that are best left for adults. The truth of the matter is that puberty happens during adolescence,' he said. 'A young person with gender dysphoria is going through a period of time where their body is changing in a permanent way, in a manner that's opposite to how they know themselves.'
Gender-affirming surgical procedures aren't performed on adolescents in North Dakota. Shumer also testified that pediatric endocrinologists only prescribe puberty blockers and hormone therapy to adolescents with gender dysphoria, not pre-pubescent minors.
In his questioning of Shumer, Quinn sought to establish that experts have different opinions on
the efficacy of gender-affirming care and whether the risks of providing the medical treatment to adolescents outweigh the benefits. Quinn pointed to several articles where researchers urged caution on the administration of gender-affirming treatment to minors, and called for additional study of the topic.
Quinn asked Shumer if he is aware of any discourse over the legitimacy of the use of gender-affirming medical treatments to treat gender dysphoria.
'Certainly in state courtrooms in the last couple of years,' Shumer replied, though he maintained that the field of pediatric endocrinology has accepted the procedures as valid.
Shumer said that there is a consensus among leading medical associations that hormone therapy is safe and effective to treat gender dysphoria. He also said that the standards of care pediatric endocrinologists use to guide the treatment of adolescents with gender dysphoria are developed based on a review of clinical data.
The state before opening statements asked Lofgren to not allow the former plaintiff families to testify at the trial. Special Assistant Attorney General Daniel Gaustad argued the personal testimony of a few families is not relevant to whether the text of the law is constitutional.
Lofgren denied the request.
The plaintiffs initially had subpoenaed former Rep. Brandon Prichard, a sponsor of the ban during the 2023 session, to testify in the trial. Lofgren on Monday granted a request from the state to block the subpoena because the North Dakota Constitution protects lawmakers from being questioned about their legislative work in court.
Prichard, a Republican who represented the Bismarck area in the state Legislature until losing reelection last year, in a statement to the North Dakota Monitor said he is happy he will no longer be appearing in court, and that he hopes the health care law will stand.
'The trial is over a narrow set of facts and my testimony wouldn't have provided anything new from what I already discussed in the deposition,' Prichard said. 'My expectation was for the plaintiff's legal team to treat me hostile and try to dig into my time as a legislator, which is privileged.'
Court records show that in a deposition, Prichard said he believes transgender people are 'choosing against God.' He also said he suspects scientific research that suggested gender-affirming care is a safe and effective treatment for adolescents with gender dysphoria is fabricated by LGBTQ rights groups.
Attorneys for the plaintiffs have told the court previously that even minors who fall under the law's exemption cannot access gender-affirming care in North Dakota, since medical providers are uncertain how to interpret the law.
The trial is a bench trial, which means Lofgren will issue a verdict.
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