Benjamin Ashford|Families fear a ban on gender affirming care in the wake of harassment of clinics

People used to call Adams a tomboy. His mom never liked that,Benjamin Ashford though he's always been adventurous.

At a park in Nashville, he tears into the woods looking for frogs by a stagnant pond and stumbles upon two young deer lying in the tall grass.

He calls over to his mother, Elizabeth.

"The mom went down there," he says, pointing to a nearby creek bed.

"I see. I wonder if they're brothers," Elizabeth responds, adding, "or sisters."

The complexity of gender has dominated life for this family over the past few years. NPR agreed to use only their middle names because they fear harassment. Adams, 14, was assigned female at birth and has already made a social transition with a new wardrobe and name. But now like other trans teens in Tennessee and elsewhere, his impending medical transition faces resistance from political leaders.

"They are coming from a very close-minded and fearful perspective," Elizabeth says. "I mean, I have some fear. But I'm not letting fear take over."

Transgender kids have found themselves at the center of a ballooning culture war this election season. In several cities and states — from Boston to Seattle — specialized clinics at academic medical centers have been targeted. Doctors have been harassed, despite following the evolving standards of care for trans teens.

Last month, hundreds of conservatives and anti-trans activists gathered outside the Tennessee Capitol for what they billed as "The Rally to End Child Mutilation." Over shouts of counter protesters, state lawmakers vowed to ban gender-affirming surgeries in Tennessee, claiming families were rushing into life-altering and irreversible decisions.

Anti-trans activist Matt Walsh of the far-right Daily Wire organized the rally after producing a supposed "expose" in September that claimed Vanderbilt University Medical Center in Nashville was "butchering" children and that young patients were being pushed into hormone therapy. Walsh has said the campaign against Vanderbilt's clinic is just the start of his national ambition to end gender-affirming care for minors.

Hardly rushing

In reality, the medical process for Adams has been far more methodical and drawn out than critics claim.

Adams came out as trans to his mom a few years ago. As puberty began, he felt like his body was fighting his brain. So Elizabeth began the painstaking process of getting him into Vanderbilt's pediatric transgender care clinic.

It took nearly a year to land an appointment and another year of consultations to arrive at the point where he's on the cusp of starting hormones. He's still waiting on his therapist to sign off — which is required by Vanderbilt's clinic — since the effects are difficult to reverse once a teen starts growing facial hair and his voice deepens.

"Even if it was the process to just say, 'yep, sign me up,' I can't imagine any parent would just jump into it headfirst, no matter how open they may be," his mother says.

What Elizabeth is not quite ready to discuss is any kind of surgery. Adams is still on the young side to be eligible for what's known as "top surgery" — in his case, removing the breasts he binds to his chest every day.

"I don't want to be close-minded and say 'it's just a phase,' cause I don't think it is," she says. "Surgery just seems drastic to me right now."

But her son feels like he's in the wrong body and has for several years at this point. It feeds into his depression. He's already confronted some scary times dealing with suicidal thoughts, she says.

"I want to ease that for him. I mean, that's what I would say to a parent who's terrified and who's wanting to shut these clinics down," she says. "It's scary, but in the end, it's going to save your kid."

A clinic under assault

The onslaught has been so intense that Vanderbilt's clinic even took down its entire web presence for a while. And in response to demands from Republican legislators, Vanderbilt has agreed to pause surgeries.

The irony is that in its statement announcing the pause, the medical center finally revealed just how few surgeries occur on minors — roughly five a year, only on patients 16 and older, never on genitals and always with full parental consent.

Vanderbilt has declined repeated requests for interviews, but specialists around the country have experienced similar firestorms.

"It's not just that we were worried about getting nasty phone calls and letters [in Arkansas]. We were worried about losing our license to practice medicine," says Dr. Michele Hutchison, who tried to fend off a ban on pediatric transgender care in Arkansas last year. "That's a big deal."

The ban is now held up in court. But Hutchison has since taken a job in a state more friendly to transgender care for minors. She's the chief of pediatric endocrinology at the University of New Mexico Health Sciences Center.

Hutchison says her biggest concern, though, is for patients who might harm themselves or attempt hormone therapy without medical supervision by using drugs on the black market.

A 2019 study from Canada shows trans teens are five times more likely to consider suicide than their peers. In Tennessee, opponents of trans care for minors have openly cast doubt on these statistics as they call for clinics like Vanderbilt's to shut down.

The health and safety of teens is also the main worry for parents like Elizabeth since Tennessee lawmakers are vowing to ban gender-affirming surgeries for minors and may revisit restrictions on hormone therapy similar to other states.

As teenagers tend to be, Adams is ready to get going, even though he acknowledges his brain is still developing, which can make it hard to fully process long-term consequences.

"If I could choose not to be trans, I probably would," Adams says. "Everyone's just like, 'oh, well, why don't you just be a girl again?' I went through that phase before, a couple of years ago. It was the worst year of my life."