To begin with, just the irony in the name of the bill is unbelievable. I am a practicing pediatrician who lives in Alabama and has taken care of patients in this state, Florida, Tennessee, and Minnesota for more than 20-plus years.

To call this bill “Vulnerable Child Compassion and Protection Act” is a disgrace to all those who provide care for children and adolescents, whether medical, mental health, or school support. We understand that children are vulnerable and need compassionate comprehensive medical and psych-social services and equal protection under the law.

First, let’s look at the law. The proposed bill criminalizes hormonal or surgical therapy for a minor or even maintaining confidentiality between a young person and their physician, therapist, nurse, or school staff and their parents.

AL.com’s Mike Cason reported last week that Rep. Wes Allen, R-Troy, In announcing his bill, said children with gender dysphoria should receive mental health counseling but not medications or surgeries that cause physical changes. Under his legislation, doctors could be charged with a felony punishable by up to 10 years in prison for prescribing puberty-blockers or hormones to anyone under 19. Surgeries on minors to change their bodies to align with their gender identities would be prohibited. The bill prohibits teachers, principals, and school counselors from withholding from parents information that a student identifies as transgender.

As a pediatrician, I and other health/mental health providers understand that the age of consent in AL is 14 for a multitude of services, including family planning. I believe this would include gender dysphoria, as those patients would seek and need access to contraception or reducing/eliminating menstruation, especially in a female born patient that is gender-questioning and is distressed by having menstrual cycles.

Speaking of distress, I and other medical and mental health providers know how important maintaining confidentiality is when treating a minor patient, especially when some of their mental health and physical conditions may be threatened by their home or school environment. We also knowingly tell patients that if we feel they are at risk of suicide, we will need to intervene to provide our patients with a stable environment, even if it means breaking that confidentiality.

Nationwide, less than 1 percent -- 0.7 percent -- of children age 13-17 identify as “trans, genderqueer, gender questioning, gender fluid, or gender dysphoric (TGD)." Of these about 56 percent reported suicidal ideation with 31 percent having a prior suicide attempt, compared to 20 percent and 11 percent cisgender youth (those who identify with their birth sex).

TGD youth also may resort to obtaining hormone therapy online or on the street. This, of course, puts the patient at risk for incorrect and possibly irreversible treatment and increasing their potential exposure to bloodborne illness.

The American Academy of Pediatrics (AAP), a group of 67,000 pediatricians across the world, issued this policy statement in 2013: “TGD youth should receive education and referral for the process of transition and how to avoid pitfalls of using medicines not prescribed by a licensed physician.”

When it comes to mental health issues, it has been proven beyond doubt, that TGD patients have fewer mental health issues when they are in a gender-affirming, supportive environment. This can be on a social (acceptance by family and school staff, etc), legal (which can’t happen in Alabama until a patient has proof of surgery), medical (hormone therapy), and surgical level.

The bill seems to suggest that gender dysphoria is a psychological disorder and as such does not require medical therapy. However, certainly,many psychological disorders, for example, bipolar disorder, depression, anxiety are readily treated with a bimodal approach of therapies with both counseling and medications.

Also in that same AAP policy statement, it is stressed that such care should be confidential, especially when there are risks of harm from the family. When a child either discloses to the physician, or to the parent and is brought in for a visit, the first recommendation is mental health support, for the patient, and the family if the pediatrician does not feel the child would be more at risk in a non-accepting home environment.

It is well documented the number of LGBTQ children who become displaced from their homes, do not attend school, and are at increased risk of violence due to not being accepted.

Medical therapy: While a patient is receiving appropriate mental health treatment, only then should hormone therapy be considered. The AAP also in their 2013 policy states “supportive counseling is paramount to assist the patient with any dysphoria and to explore gender roles BEFORE altering the body.” As stated by opponents to hormonal therapy in trans/questioning patients, some patients who display gender dysphoria may change their minds as they get older. However, more will become stressed by physiologic pubertal changes, which typically start around age 11.

Patients at that age would benefit from GNRH (a hormone that suppresses biological pubertal changes) and have effects that are reversible, meaning this therapy can be stopped without negative effect at any time. Pubertal suppression has been shown to improve psychological functioning in TGD adolescents.

By the age that pubertal changes would naturally end (ages 16-18), a patient that identifies as having a gender different than their biological sex, can be a candidate (while still receiving counseling) to receive hormonal therapy different from their birth sex. Some of these effects, as the author states, are irreversible, but not all. Some patients can feel gender affirmed without ever receiving medical therapies. To summarize, not every gender dysphoric patient will and should receive hormonal therapy of any kind, and those who do should be in counseling with suppressive hormones not initiated until at least age 11 and “cross-sex” hormones until after the age of 16.

Surgical therapy: Those listed in the bill are not recommended for patients under the age of 18, and again only in patients that are being followed by a mental health provider. Most places that provide surgical interventions of TGD patients have very strict guidelines before proceeding with surgery, And again, some transgender patients can see themselves as being gender-affirming without surgical interventions.

Back to consent: Age of medical and mental health consent in AL is 14. This is clearly marked in the Alabama Child Health Improvement Alliance and by the AL Department of Health. Patients who are seen at clinics providing Medicaid or Title X services (most healthcare facilities in AL) are covered under federal law (which trumps state law).

Karen J Parsell, MD, FAAP is a practicing pediatrician in Alabama and worked in several states.