The state’s only pediatric urologist fears she will have to relocate if a bill barring gender-affirming surgeries on transgender youth passes into law — even though she has never performed such a surgery on a minor.
“I don’t do gender-affirming surgery for children,” said Dr. Erin Grantham, a board-certified pediatric urologist who has been practicing at Billings Health Clinic since 2015.
But if the bill passes, she would be uncomfortable performing about 20% of the surgeries she does now that are unrelated to treating gender-dysphoria.
She and other pediatricians worry that the bill, among other things, would make their jobs harder and restrict their ability to recruit pediatric specialists to Montana, where there is already a shortage.
The vagueness surrounding the surgical and medical definitions in House Bill 427 has Grantham worried. The bill is scheduled to be heard by the House Judiciary Committee Monday.
“Gender and biological sex is not as simple as high school biology taught us about,” she said. “Biological sex is more interesting than everyone is just born male or female.”
Other pediatricians and medical faculty echoed her concern.
“It’s incredibly hard to have a comprehensive definition of what is okay and what is not,” said Dr. Lauren Wilson, vice president of Montana’s Chapter of the American Academy of Pediatrics. “[The bill] would essentially open a lot of urologic procedures to potential scrutiny, and the environment would be difficult to practice in.”
Dr. Kathyrn Lowe said the legislature should leave it up to qualified medical providers to regulate health care guidelines. “They are dictating medical care who don’t have the medical knowledge and expertise to understand all the different complicated scenarios that we face as physicians.”
Lowe is a pediatrician with the Montana Chapter of the American Academy of Pediatrics and a part-time clinical instructor at Montana State University in Bozeman. She spoke to the Daily Montanan on behalf of herself and not the school.
“The way the bill is worded, it would apply more broadly than maybe it is intended and provide a barrier of care for medical patients,” she said.
HB427, sponsored by Whitefish Republican, Rep. John Fuller, would ban surgeries for treating minors experiencing gender dysphoria. Unlike a nearly identical bill introduced by Fuller that failed earlier this session, it would not prohibit hormonal treatments such as puberty blockers.
Studies show that providing proper gender-affirming care can reduce things like suicide and depression among trans youth.
The legislation would also ban doctors from referring patients to specialists who could provide proper care, a stipulation that opponents argue violates a doctor’s First Amendment right to free speech.
Lowe said she is not aware of any other areas of medicine that restrict doctors from referring patients to get the care they need.
“That is a huge infringement on our duty as pediatricians to do no harm by our patients,” she said.
Fuller and other bill supporters say it is necessary to protect children from making medical decisions they may regret later in life.
Montana is already scarce on health providers. Only four of its counties are not designated health professional shortage areas.
Medical professionals fear this bill would make the situation worse.
“In my experience, we both have difficulty in recruiting people to sign up for this lifestyle and difficulty retaining people when they do so,” Wilson said.
For some conditions, Montana does not have a single pediatric specialist. Kids with arthritis can only see a rheumatologist when one flies to Missoula from Seattle Children’s Hospital, she said.
With Montana’s low population, it is already hard to keep pediatric specialists busy, said Dr. Jeremiah Lysinger. Depending on the specialist there needs to be between 20,000 and 150,000 children to support them full time. Montana has around 250,000 children total.
Outside of providing gender-affirming care, the pediatric specialists Montana is at risk of losing also provide critical care for kids like treating Type 1 diabetes, kidney stones or performing surgery on kids with Spina Bifida to use the bathroom correctly, he said.
Lysinger is a pediatric pulmonologist at Billings Clinic and chairs the hospital’s department of pediatrics.
“If bills like this go through and push these specialists away, then these other kids who aren’t transgender will have to travel to places like Denver, Seattle and Salt Lake City to receive care,” he said.
The other problem, he said, is ideological.
“This goes to show how Montana honors all of our kids. It’s hard to recruit any pediatricians with bills so off-putting to people who provide pediatric care,” he said.
Even as a pediatric pulmonologist, he said he finds the bill offensive.
“I went into pediatrics because I care for all children, no matter their condition, no matter their personal beliefs, no matter where they came from,” he said. “To show such bigotry against this group of transgender youth and treating them appropriately … I think globally to physicians is truly off-putting.”
By inserting the legislature into the patient-doctor relationship the way HB427 does, doctors say would Montana would become a less attractive place for pediatric doctors to practice.
Allowing the legislature to decide how to care for trans youth is a slippery slope, Lysinger said. “They’re not choosing to be transgender; it’s just who they are. So what’s next?”
No pediatrician wants to work in a state where the legislature mandates care that is outside of the guidelines provided by the American Academy of Pediatrics, he said.
“This kind of legislative interference with medicine is just going to make it so hard to recruit other specialists up here,” Grantham said.
Both the National and Montana chapter of the American Academy of Pediatricians oppose the bill.
The current bill is the reincarnation of the previously failed HB113, which banned hormonal treatments like puberty blockers as well as the surgeries listed in HB427.
The bill is part of a more significant anti-trans effort in legislatures across the country fueled by groups like the Alliance Defending Freedom — a Southern Poverty Law Center designated hate group — the same group behind HB112 that would ban transgender athletes’ participation in Montana’s K-16 sports, according to the Human Rights Campaign. The bill is waiting to be heard by the Senate Judiciary Committee.
The medical quagmire of definitions and terms in the bill have Grantham confused and concerned about what she could do as a doctor.
Two weeks ago, Grantham had a female patient whose birth certificate listed the wrong gender because she was diagnosed with congenital adrenal hyperplasia — a relatively common condition for girls that causes an ambiguous genitalia representation — as an infant.
Typically, if a girl in their late teens with that condition came to Grantham and said, “I don’t like this part that people think makes me look more like a boy, and less like a classic girl,” Grantham would have a conversation about what her options are.
But under this bill, she said that’s not a conversation she would feel comfortable having, even though it is outside of the context of transgender care.
While the bill does list several scenarios when the listed banned surgeries would be allowed, it does not cover all possible scenarios, medical professionals said.
“With this bill, there would be some patients who are born who simply need surgery to correct anatomical differences, and they would not be allowed to get that surgery,” Lowe said.
Doctors worry about the bill’s enforcement policy as well.
The policy allows patients to file malpractice claims until they are 27-years-old — about three times longer than the liability period for any other procedure done in Montana, Grantham said.
“I would likely be facing lawsuits springing up periodically long past my retirement age by people who look at this and say, hey, ‘I might be able to get some money out of this,'” Grantham said.
Medical providers could also lose their license if found guilty of violating the conditions of the bill.
But the bill goes beyond just the possibility of driving Grantham out of state. It would also prevent doctors from referring patients to other specialists for gender-affirming care.
“I think it’s horrendous to tell us as pediatricians that not only can we not provide the best-practice care, but we also cannot help our patients get that care from someone else,” Lowe said.
Aside from the bill’s enforcement and lack of clarity, doctors have said it is unnecessary because performing genital gender-affirming surgery on minors goes against best-practice medical guidelines.
Wilson said top surgeries can be performed on minors 16-years-old or older. But those surgeries are only performed in rare cases, where other measures have not been helpful and require consent from both parents as well. “It is a decision that is not taken lightly,” she said.
To perform the surgeries listed in the bill that fall under Grantham’s area of practice, she said a patient must have already transitioned socially, have explicit support from mental health providers and be 18-years-old.
“There is no transgender teenage girl who’s getting a vaginoplasty. She doesn’t exist,” Grantham said.
Guidelines in place for treating gender dysphoria call for the use of puberty blockers and other hormonal treatments.
“The right thing for the patient who is transgender is to follow guidelines so that we don’t overreact to something,” she said.
This story was updated to clarify the different types of gender-affirming surgeries.