Jaiden van Bork was a student at Nauset Regional High School when she began traveling to Boston Children’s Hospital to get gender-affirming hormone therapy. Van Bork is from Brewster, so the trip took almost two hours each way.
Van Bork says she was lucky to have supportive family members who helped connect her with resources and medical care. After online searches showed a dearth of gender-affirming care clinics nearby, van Bork said her mom found the Gender Multispecialty Service at Boston Children’s. “There certainly wasn’t anything less than an hour away from where I was living,” she said.
That was in 2018. About a year ago, Health Imperatives, a seven-site clinic with a branch in Hyannis, began offering gender-affirming hormone therapy to patients under 18. The clinic began prescribing the medications to adults in June 2019 and expanded its care options to youth in August 2022 in response to a need expressed by parents, director Julia Kehoe said.
The lack of access to care on Cape Cod wasn’t the only problem. Even for patients able to get there, Kehoe said, waiting lists in Boston were long.
“We responded to parents who were asking us to offer care for adolescents because it was particularly difficult for them to access it,” Kehoe said. Once the need was clear, she said, the decision to expand care to minors was not hard to make. “So many parents came to us because their children were at risk of dying by suicide,” she said.
According to the Trevor Project’s 2022 National Survey on LGBTQ Youth Mental Health, 45 percent of queer youth seriously considered suicide in the previous year, with particularly high rates among trans youth and youth of color. The survey also found that fewer than one-third of trans kids found their homes to be gender-affirming, and 60 percent of queer youth who wanted mental health care were not able to get it.
Kehoe said she doesn’t know of any other medical clinics on Cape Cod offering gender-affirming hormone therapy to minors.
Duffy Health Center, another clinic in Hyannis, offers hormone therapy to adults only, chief development and community engagement officer Sara Grambach said in an email. Cape Cod Healthcare executive director of communications Julie Badot referred the Independent to its pediatric partners in Boston for information on what they provide. Cape Cod Pediatrics did not respond to a request for an interview. Outer Cape Health Services (OCHS) offers hormone therapy to adults only, according to Andrew Jorgensen, a doctor who specializes in pediatrics and internal medicine.
In an Oct. 13 interview, Jorgensen said he was the primary care physician for close to 750 patients. Between 20 and 25 of those, he estimated, receive gender-affirming hormone therapy.
The reason OCHS doesn’t treat minors, Jorgensen said, is because physicians here have limited experience. “There are several of us who have received training in hormone therapy for children,” said Jorgensen. “But you don’t want to do something routinely when you don’t have a lot of experience doing it.”
Jorgensen said that kind of experience would be hard to get at OCHS, which treats many more adults than minors at its three clinics in Provincetown, Wellfleet, and Harwich. He added that OCHS supports families with trans youth by connecting them with medical centers in Boston, including the program at Boston Children’s Hospital that van Bork’s family found.
OCHS communications officer Gerry Desautels said that in 2022 8.7 percent of OCHS patients were under age 18.
Putting Puberty ‘on Pause’
The World Health Organization defines gender-affirmative health care as “social, psychological, behavioral or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.”
Hormone therapy is an option for trans people beginning in mid-adolescence, according to the Association of American Medical Colleges, “to increase their levels of estrogen or testosterone so that they develop sex characteristics more closely aligned with their gender identity.”
Gender-affirming hormone therapy is different for adolescents than it is for adults. Young people who have begun puberty are typically prescribed gonadotropin-releasing hormone (GnRH) analogs, known as “puberty blockers,” to suppress the development of secondary sex characteristics. According to the Mayo Clinic website, GnRH analogs “pause puberty” and “don’t cause permanent physical changes.”
Gender-affirming hormone therapy usually is not stand-alone care. Kehoe said that the Hyannis branch of Health Imperatives links patients with support groups like We Thrive! Other programs are offered through Fenway Health in Boston.
In the past year, the Hyannis Health Imperatives clinic has treated 24 adult patients and four patients under age 18 with gender-affirming hormone therapy. At all seven Health Imperatives locations combined, 136 patients sought the treatments and only 10 of them were adolescents. Patients typically come in every three to six months for lab tests, said Kehoe.
Allies and Antis
Ann Burke works at Fenway Health and founded the Cape & Islands Transgender Resource Fund, “a small grassroots group of transgender people and allies.” The fund collects donations and uses them to help trans people with essential costs like food, medication, and housing. The fund can help bridge the Cape accessibility gap, Burke says.
When a patient needed to get to Boston from the Outer Cape for gender-affirming surgery, someone from the Outer Cape volunteered to drive them. The fund paid for the patient to spend the night in Hyannis “so that the person driving just had to backtrack a little bit, pick them up, and then jump on the highway and go up to Boston for the day of their surgery,” Burke said.
Burke also leads support groups in the Violence Recovery Program at Fenway, which includes groups for queer people of color and asylum seekers fleeing persecution related to gender. The program is funded by grants from the Mass. Office of Victim Assistance and the federal Office of Violence Against Women; because of grant stipulations, it is available only to adults.
One issue for young trans people seeking care is that they are likely to encounter something called adultism — the inverse of ageism — in which they aren’t taken as seriously as their older counterparts, said Scott Fitzmaurice. He is founder and director of We Thrive!, a community-building group in Hyannis for queer people age 22 and younger. That group is part of the Cape & Islands Gay & Straight Youth Alliance, which Fitzmaurice founded in 1996.
“We work through an age-free lens,” said Fitzmaurice. “We find that when LGBTQ folks come together in an environment that is culturally queer, they tend to reach more extraordinary places in their lives just by not having to deal with the dominant paradigm.”
The dominant paradigm appears to have led to an onslaught of anti-trans legislation.
So far this year, 583 anti-trans bills have been introduced in state legislatures across the country, according to the research organization Trans Legislation Tracker. The bills target trans rights across the board, from health care to athletics to education. Eighty-five of those bills have been passed. The year before, 26 such bills were passed.
Trans Legislation Tracker is keeping tabs on 36 bills at the federal level that would restrict trans rights. U.S. House Bill 1399, titled the “Protect Children’s Innocence Act” and introduced by Rep. Marjorie Taylor Greene (R-Ga.), would make it a felony to give gender-affirming care to minors. Gender-affirming surgeries and hormone replacement therapy all fall under the health-care umbrella that the bill seeks to criminalize.
Although Massachusetts is among the better states in which to be a trans youth, it’s not immune to the nationwide legislative attack on trans rights. Republican Rep. David DeCoste of Norwell introduced House Bill 458, “An act relative to parental rights in education,” in July.
That act seeks to bolster parent control, stipulating that “classroom instruction by school personnel or third parties on sexual orientation or gender identity may not occur in kindergarten through grade 3 or in a manner that is not age appropriate or developmentally appropriate for students in accordance with state standards.”
Locally, Kehoe said that Health Imperatives has not faced backlash for offering gender-affirming services. But that care is among an increasingly politicized list of services that are provided only by Health Imperatives on the Cape. At the Sept. 8 planning meeting for a 40-day protest against abortion outside the clinic, campaign organizer Sheila Quinn touched on Health Imperatives’ other services: “They do a few other things like gender reassignment counseling and hormone distribution as well, so they do a lot of unsavory activities.”
Gender-affirming care appears to be saving young people’s lives. Research published in the National Library of Medicine in 2020 tracking puberty blockers’ effects on trans youths’ mental health showed that the medication significantly decreased suicidal ideation in those who opted for treatment.
Before puberty, Dr. Jorgensen of OCHS said, a professional’s role can be “more about helping the family and the child explore their gender, their own realization of who they are.”
Fitzmaurice and Burke have begun hosting gatherings in Hyannis for kids ages 5 to 12 on the gender continuum. Fitzmaurice noted that he uses the term “on the gender continuum” over “trans.”
“I think it better reflects the work,” he said.
Those Hyannis gatherings include pizza and crafts, said Burke. And emotion, said Fitzmaurice: “We could tell the parents were getting a recharge that they needed,” he said, as well as information.
After a recent gathering, Fitzmaurice said he asked a parent when a convenient time would be for the next meeting. “He said, ‘This gathering is about my child’s mental health, so it comes before everything else,’ ” Fitzmaurice said.
Kehoe sees gender-affirming care as essential. “It’s as critical as anything we offer, because it’s not only life-affirming, it’s life-saving,” she said.
Van Bork, now a sophomore at Brandeis University studying film, agreed, although she worries about how difficult it is for young people to find the help they need.
“Genuinely, I think that gender-affirming care has saved my life,” she said. “And I think that I am probably one in a million in terms of that.”