Transgender care trial ends with witness questioning the ethics of providing care to minors

The Richard Sheppard Arnold Federal Courthouse in Little Rock is shown in this Jan. 16, 2021, file photo. (Arkansas Democrat-Gazette/Dale Ellis)
The Richard Sheppard Arnold Federal Courthouse in Little Rock is shown in this Jan. 16, 2021, file photo. (Arkansas Democrat-Gazette/Dale Ellis)

Testimony concluded Thursday in a federal bench trial that will decide the constitutionality of Arkansas' first-in-the-nation ban on gender affirming health care for minors with a pediatric endocrinologist from St. Louis who said he has been studying the issue for 10 years and has concluded that until more is known, doctors who provide such care are doing so unethically.

Dr. Paul Hruz, who specializes in childhood diabetes was on the witness stand for four hours Thursday as he drilled down into much of the medical minutiae involved in pediatric endocrinology and assailed previous studies as only proving that more study is needed into such treatments.

At one point, U.S. District Judge James M. Moody Jr., the presiding judge who will decide on the matter, grew impatient, and urged defense attorney Dylan Jacobs to hurry things along.

"He's already testified to that at length," Moody said, exasperated, "for hours."

Moody has not indicated a timetable for a ruling in the matter.

The trial -- which is being held before a judge rather than a jury -- is to decide the constitutionality of Arkansas Act 626 of 2021, the Save Adolescents From Experimentation Act. The law was passed in March 2021 after both the state House and Senate voted by large margins to override a veto by Gov. Asa Hutchinson. It was challenged the next month in a suit filed by the American Civil Liberties Union, and three months later, a week before the law was set to go into effect, Moody issued a temporary injunction blocking it from being enforced while the matter is in court.

A three-judge panel on the 8th U.S. Circuit Court of Appeals upheld Moody's injunction in August. The court ruled earlier this month that it would not take up the matter for reconsideration by the full 8th Circuit, denying an appeal motion of Moody's ruling filed by Attorney General Leslie Rutledge's office. The lawsuit, which was filed by the American Civil Liberties Union on behalf of the plaintiffs, contends the law violates the equal protection and due process clauses of the 14th Amendment and free speech protections under the First Amendment.

Plaintiffs in the case, represented by attorneys from the American Civil Liberties Union, are Dylan Brandt, Parker Saxton, Sabrina Jennen and Brooke Dennis and their parents, Joanna Brandt, Donnie Saxton, Aaron and Lacey Jennen, Shayne and Amanda Dennis, and two physicians who provide health care for transgender teens, Dr. Michele Hutchison and Dr. Kathryn Stambough.

Defendants in the case, represented by a legal team from the state's attorney general's office, are Rutledge, Medical Board Director Amy Embry and the 14 members of the state medical board.

Hruz testified that there are uses for puberty blockers and hormone therapy in treating minor patients and went over those treatments in great detail but he steadfastly maintained that not enough is known about the efficacy or the long-term safety of their use to justify use in the treatment of gender dysphoria.

Gender dysphoria is defined by the Mayo Clinic in Rochester, Minn., as the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex at birth or sex-related physical characteristics. Current treatments for the condition, in addition to psychotherapy, range from gender affirming hormone treatments to surgical procedures, some of which were described in graphic detail in testimony over the previous four days.

Hruz said off-label use of testosterone for purposes such as increasing muscle mass in athletes or in adolescents concerned about body image would be frowned upon by the medical community. He said for a child who had experienced normal puberty and was in what would be medically considered a normal stage of development, "most, if not all practitioners would consider it malpractice to be inducing increased lean body mass for the desires of that individual."

"That's the reason testosterone is a controlled substance," he added.

Regarding testosterone therapy for transgender boys, whom Hruz deemed to be female, "I'm not aware of any indication where we would give testosterone to a female."

The trial concluded Thursday after eight days of testimony broken up by a five-week recess because of scheduling difficulties. ACLU attorneys completed their case in October during the first week of trial with testimony from several medical and psychiatric experts as well as testimony from several of the plaintiffs, including Dylan Brandt, whose name is in the title of the lawsuit dubbed Brandt et al vs. Rutledge et al.

During his testimony, the strapping 17-year-old with a full beard and confident bearing testified about the anxiety and depression he suffered when he reached puberty as his body began changing in ways that clashed with his gender identity and he said coming out to his mother as transgender was like a weight lifted from his shoulders. Hormone replacement therapy, he said, further alleviated his depression.

"My outside finally matches the way I feel on my inside," he said to the court.

Joanna Brandt, Dylan's mother, described her son as "an exceptional human being," who she said is "wise beyond his years and one of the most emotionally intelligent people I know."

Donnie Saxton and Aaron Jennen both talked about their fears for their children, Parker Saxton and Sabrina Jennen, both 17. Both men described their reactions when their children came out to them as transgender and the efforts they went to in order to educate themselves on the issue and what the medical procedures entailed.

Hutchison, the former medical director of the Arkansas Children's Hospital Gender Spectrum Clinic in Little Rock, testified that the effects of transgender therapy were transformative on the patients she treated. She said most came to her suffering from depression and anxiety and were withdrawn socially. She said many patients had a history of suicidal ideation or self-harming behavior.

"Very rarely did I ever have a patient come in on that first visit talking about their future," she said.

Stambough, the current medical director, echoed Hutchison's testimony. In response to the state's contention that minor patients can simply wait until they turn 18, she said withholding care for those patients makes time a ticking time bomb as their bodies continue to develop in ways that don't fit their gender identity.

"Not every patient would make it to 18," she said.

During this week's testimony, Moody heard from expert witnesses on the opposite end of the spectrum, including Hruz; Dr. Stephen Levine, a clinical psychiatrist at Case Western Reserve University School of Medicine in Ohio; Dr. Mark Regnerus, a sociologist with the University of Texas at Austin; Dr. Patrick Lappert, a cosmetic surgeon who practices in Decatur, Ala.; and Dr. Roger Hiatt, a child and adolescent psychiatrist who works in Arkansas and Tennessee.

Levine testified Monday that the standards of care established by the World Professional Association for Transgender Health are intended to advocate for transgender affirmation therapies and not to address the root causes of gender dysphoria.

On Wednesday, anti-transgender activists Laura Smaltz of Oklahoma and Louisiana native Billy Burleigh, both formerly transgender people who transitioned and detransitioned as adults, testified to the religious conversions they experienced that persuaded them to go back to their natal genders.

Also on Wednesday, Hiatt testified in favor of a ban on hormones, puberty blockers and surgery for transgender youth, saying that he has worked with hundreds of transgender teens in the past 25 years. He said that despite the fact that most retain their trans identities, he supports the health care ban for minors.

After the conclusion of Hruz's testimony Thursday, Moody signaled the end of the trial with a simple, "OK, we're adjourned," giving no indication of which way, if any, he might be leaning in the matter. The judge gave no indication of when a decision can be expected other than telling attorneys at the beginning of the trial not to expect a quick turnaround on his ruling.