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An NC doctor found ‘joy’ treating transgender youth. Now his job is at risk

Riley Smith keeps meticulous records of all sorts of information for around 25 patients — what treatment they’re getting, the date their treatment started, parental consent records and other data.

Diligent note taking has become more essential to his job than ever. His medical license in North Carolina now depends on it.

Smith is a family physician and an assistant professor at UNC School of Medicine. He provides medical gender-affirming care for adolescents, in addition to adults.

It’s a part of his profession that he always loved, he said. But he can’t provide that care much longer in North Carolina.

House Bill 808, which was approved by Republican lawmakers over the veto of Gov. Roy Cooper, effectively bans most forms of gender-affirming care — such as puberty blockers, hormone therapy and gender transition surgeries — for minors. Exceptions are included for adolescents with sex development disorders or minors who started their treatment before Aug. 1. Physicians who violate the ban will have their medical license revoked, under the new law.

“There was maybe at least a glimmer of hope that something might change and the bill would not actually pass,” Smith said. “But now, it definitely feels very real.”

The bill puts physicians like Smith in limbo as they continue to provide care for patients who started gender-affirming treatments before Aug. 1. Smith estimates there are a few dozen doctors who provide gender-affirming care in large state health systems like UNC or Duke.

Any patient under 18 seeking gender-affirming care now will have to consider out-of-state options. Virginia is the closest state without a ban in place or being considered.

In preparation for the bill’s enactment, Smith spent as much time as he could with families looking into gender-affirming care. The stress of their fate — and his — has weighed on him, and at times, he said, he felt powerless.

“We know what this impact is going to be,” Smith said. “But there’s only so much that you can do.”

More than 20 states have passed restrictions on gender-affirming care for people under 18, according to the Human Rights Campaign. In some states, including Florida, providers can be charged with a felony.

‘A very rewarding career’ in gender-affirming care

Around 7:30 a.m. on days Smith does clinical work, he checks to see what patients he’ll see that day.

He might spend time with patients in the hospital. There may be babies to deliver. General primary care is typical for his list of things to do.

But of all the medical services Smith offers as a family physician, one of the most “joyful parts” of his job is providing gender-affirming care to minors. It’s one of the few areas of his profession where patients want to come to the doctor and take their medicine, he said.

“They are happy with everything that the medicine is doing for them and it is truly improving their life every single day,” said Smith, who emphasized that he was speaking for himself and not the clinic or the university.

He said he’s been told by several parents that his medical services made them feel that “they have their kid back” after their child experienced debilitating bouts of suicidal thoughts and depression.

“If more people saw that, then these laws wouldn’t be happening,” Smith said.

Two-thirds of transgender teenagers were found to have depression, according to research submitted to the Endocrine Society and published in the Journal of the Endocrine Society. A study from the Trevor Project, a suicide prevention group for LGBTQ youth, showed transgender adolescents at a higher risk for suicide than cisgender youth.

Smith acknowledges those findings, but he tries to highlight positive stories of his adult transgender patients who are successful engineers, lawyers and teachers to his younger patients.

“This is a normal part of human experience, and it’s a way we can support people in being their authentic selves,” he said.

Advocates opposing veto overrides of bills banning transgender athletes and restrictions on gender-affirming care for minors hold a press conference at the Legislative Building in Raleigh on Wednesday, Aug 16, 2023. Travis Long/tlong@newsobserver.com
Advocates opposing veto overrides of bills banning transgender athletes and restrictions on gender-affirming care for minors hold a press conference at the Legislative Building in Raleigh on Wednesday, Aug 16, 2023. Travis Long/tlong@newsobserver.com

‘Did not foresee’ NC legislation on transgender health care

Everyone seems to have an opinion on transgender rights, Smith said, but “I did not foresee this being an issue in my career.”

“I don’t know what others thought,” he said. “Maybe I was naive.”

He now worries about telling people he is a gender-affirming care provider. His profession never felt fringe within the medical world, but a lot has rapidly shifted.

Smith, who is from North Carolina, went to Northwestern University and Ohio State University, where he gained his passion for LGBTQ health. He and his wife eventually landed at the University of Colorado for their residencies.

From the start, Smith provided gender-affirming care at his residency clinic.

Eventually, he had adolescents coming from across eastern Colorado because his clinic was the closest to them, Smith said.

During his residency, Smith “deeply and strongly advocated” for his adolescent patients who were pursuing gender-affirming care, said Elizabeth Kvach, Smith’s mentor and Denver Health’s LGBTQ+ health services medical director. He had frequent follow-up visits to ensure they weren’t “falling through the cracks,” she said, which showed his dedication.

“Dr. Smith is such a high caliber physician and I would send my own family members to him,” she said.

Doctors fearing for their safety

Over the past few years, it’s become a “scary climate” for doctors who provide gender-affirming care, Kvach said. She worries for all providers who may face restrictions, and her institution has already taken steps to safeguard Colorado physicians.

“I myself have certainly taken measures to try to protect myself and the work that we’re doing in Denver,” Kvach said.

They removed the names and faces of staff members who provide gender-affirming care from Denver Health’s website, Kvach said. They also deleted social media accounts, videos that reveal where certain practices are and other internet presences.

A family physician in the Triangle who asked not to be identified for fear of harassment or negative impact on her employment, said she’s concerned about the “demonizing and criminalizing” of gender-affirming care in North Carolina.

When she came to North Carolina for her residency five years ago, she hoped to gain the skills to incorporate youth-focused gender-affirming care into her primary care practice. She also wanted to provide abortion care.

HB 808 and the 12-week abortion law ended that dream, the doctor said. It isn’t feasible for her to include that care in her daily practice, she said, due to legal hoops she needs to jump through as a family physician.

Looking at the way legislation has progressed in North Carolina, the doctor said she wouldn’t train in the state if she was a prospective student now.

As she prepares for a new job elsewhere in North Carolina, she said she needs to make “calculated decisions” to protect her well-being. She’s selective about who she gives her cell phone number to and which phone calls she answers.

Feeling optimistic can be difficult, she said. Even if the legislation is reversed, there will still be a “really long turnaround time of undoing,” she said.

“I just really, really, really, really want politics out of the exam room,” she said.

Provider education on gender-affirming care

Some groups around North Carolina continue to educate physicians on gender-affirming care — now more so on treating transgender adults — despite HB 808. Charlotte Trans Health, or CTH, teaches local doctors how to incorporate gender-affirming care into their daily practice.

The group has recently received more requests for training to navigate the political landscape, said Holly Savoy, one of the CTH founding members. National health groups have also stepped in to teach topics like how to testify in a state legislature or doctors’ privacy issues.

Casey Mesaeh, the CTH administrative and community education coordinator, has considered leaving the state. They grew up in Western North Carolina and have “complex feelings” about leaving the South.

“I don’t necessarily know if the South is always going to be a place where it’s viable for me to do that,” Mesaeh, who is a member of the transgender community, said.

For now, Mesaeh plans to continue their work at CTH. Even if transgender youth can’t get the transition medication needed, Mesaeh said, they will still need doctors in North Carolina who can maintain an “affirming” relationship with them.

“A lot of our providers, even if their work is limited, are still going to be seeing trans kids,” Mesaeh said. “These kids will continue to be trans, whether or not they’re on hormones.”

Savoy and Mesaeh said CTH has seen continued membership growth and support from the Charlotte community.

Charlotte Trans Health started with 13 providers. In 2022, that number was 67, Savoy said in an email. Membership increased to 78 providers as of Aug. 8, and Savoy said she expects the group to keep expanding.

Uncertain future for transgender youth health care in NC

A year has passed since Smith returned to North Carolina to continue his medical career. Despite having a “wonderful experience” at UNC, the last few months have been one of the hardest times in his life.

He’s seen families who are “devastated” by what could happen to their child’s health care in light of HB 808. Most of the time, they come to him with questions on what their child’s future will look like.

There are aspects of the bill that Smith is still navigating himself — specifically the bill’s continuing care and medical malpractice clauses.

HB 808 does not prohibit youth patients from “continuing or completing a course of treatment.” That includes undergoing surgery, receiving hormone therapy or taking puberty blocking drugs. The deadline laid out in the bill was Aug. 1 for patients with “active” ongoing treatment.

It’s unclear what is defined as a “course of treatment,” Smith said. He’s sought guidance on that issue, and the safest conclusion Smith has come to is that a patient was prescribed their medication before Aug. 1.

“I’m not a lawyer. I’m not a politician. I don’t know who is going to interpret this law somehow,” Smith said. “It is absolutely something that is on people’s minds and what we’re trying to make sense of.”

That’s when the thorough notetaking became necessary. To keep track of which patients seemed to qualify for a continued “course of treatment,” he needed to ensure his records could hold up to any challenges.

Smith struggles with the idea of turning people away who need his care, but who didn’t meet the deadline. He still can talk to patients about nonprescription transition options, but in many cases, that means leaving North Carolina.

The bill also includes a medical malpractice clause, which Smith called “completely unprecedented.”

The bill allows a patient or a patient’s parent to sue a physician who performed gender-affirming care for physical or emotional damage up to 25 years after the patient turns 18.

The typical statute of limitations for medical malpractice in North Carolina is four years, according to North Carolina law.

Several gender-affirming care providers were sued in July by a former patient seeking damages for their treatment. The plaintiff, Prisha Mosley, is a detransitioner — someone who reverts back to their original gender identity after transitioning — who testified in support of HB 808.

“I worry something like that is going to scare providers,” Smith said. “It scares me. That is a very, very, very long time to be liable for something.”

But Smith said he is committed to providing legal health care to those he can. At the very least, he can refer patients to other people who can help them receive care he can no longer give, he said.

There may also come a time when Smith himself may need to leave. Smith and his wife have started discussing whether their future is in North Carolina. He considers the state home, he said, and wants to raise his family here.

For now, Smith said he doesn’t think he can leave — there will still be children who need his care, and he wants to be here for them.