In my role as a legislator, physician, advocate and human being, I have asked Gov. Ayotte to veto HB 377 and 712. These bills would ban the prescription of puberty blockers and breast removal surgeries on minors as part of gender-affirming care in the state of New Hampshire and allow for civil penalties for physicians who violated these proposed laws.
In short, the sponsors of these bills support the concepts of liberty and freedom as well as parental rights. Yet, in authoring these bills, they are, in effect, saying these ideals do not apply to transgender children or their parents. Enforcing their narrow point of view on a vulnerable group is blatantly discriminatory.
Furthermore, it is an invasion on the sanctity of the Doctor-Patient Relationship. In effect, by proposing these bills, an un-trained legislature is practicing medicine by making a one-size fits all treatment recommendation for an extremely complex medical issue.
I have practiced medicine in New Hampshire for forty years. I have always been attracted to medical problems that defy easy answer. My patients deal with complex medical problems that affect them biologically, psychologically and socially. Their problems are unique, and there is no one-size fits all solution. Evidence base and best practices are frequently lacking. We work together — health care team, patient and family — to create patient-centered solutions that work for them. Great care and thought goes into each step. Life-changing, invasive strategies are only used when all else fails.
For children, the issues are much more complicated. They are not neurologically and structurally mature until they are 25 years of age, and the effects on that maturation as well as long term effects of any intervention need to be considered, which makes their care dramatically more complicated, certainly well beyond the abilities of the typical legislator.
That is most certainly true for gender-affirming care for minors. The bills’ sponsor stated in her testimony that these individuals should wait until they are eighteen to have them performed. In ideal circumstances, I would say the individual should wait until age 25, when they are neurologically mature. One lesson I learned early in my career is that the ideal world and the real world often differ. For a small number of adolescents, waiting can be deadly. The decision to proceed is justified, but only after long and careful consideration and exhausting all other options.
Taking these options off the table, as HB 377 and 712 would do, is medically and legally irresponsible.
While the exact number of New Hampshire adolescents receiving pubertal blockers is not known, if the epidemiology of this issue in New Hampshire follows national trends, 24 adolescents would be receiving this therapy (Hughes, L et al, JAMA Pediatrics, 179).
There is no clear evidence that any female adolescent has ever had breast removal surgery in New Hampshire as part of gender-affirming care, making HB 712 the so-called solution in search of a problem. This is not the pervasive issue the sponsors would have us believe.
To date, gender-affirming care in New Hampshire, by all reports, has followed the proposal I have outlined and best practice guidelines, which makes these bills unnecessary. We should be proud of that. The sponsors of this bill voiced concern that gender-affirming clinics, found elsewhere, could invade the state and behave substantially less responsibly. I would agree that is a legitimate concern, yet one that is much better addressed by referring oversight to the much more able Board of Medicine through creation of rules, thoroughly reviewed and enforced by experts.
But there is another very important concern. One rule we learn as legislators is our primary responsibility, above all else, is the wishes of our constituents. The opposition to these bills was a ratio of 58 – 1. Given that, I would argue that enacting these bills would be legislative malpractice.
What I do love about being a legislator is the free flow of ideas. We all have the right to voice an opinion. However, small groups, armed with their prejudices, do not have the right to enforce their will on the larger group, especially when that is to the detriment of another group, however small. It is incumbent on all of us as citizens to not let this happen, especially not to those so vulnerable.
And so, again, I call on Gov. Ayotte to do the right thing and veto these bills.
Rep. David Nagel, MD, represented Belknap District 6 in the New Hampshire State House. He lives in Gilmanton.