Ruling in North Dakota transgender health care case likely months out as trial wraps

A seven-day trial over North Dakota’s ban on gender-affirming care for minors concluded Tuesday, though a final decision on the case is still months away.

The state in 2023 made it a crime for health care professionals to provide the treatments to anyone under 18. 

A lawsuit brought by North Dakota pediatric endocrinologist Luis Casas alleges that the ban is an unconstitutional infringement of personal autonomy and equal protection rights.

South Central District Court Judge Jackson Lofgren took the case under advisement Tuesday. He asked the plaintiffs and defense to present their closing arguments in legal briefs to be filed at a later date.

Gender-affirming care for minors hangs in balance as North Dakota trial begins

The state of North Dakota wrapped up its side earlier that day with testimony from Stephen Levine, an adult psychiatrist.

Levine has been a psychiatrist since about 1970, and was a committee chair of a group that would later become the World Professional Association for Transgender Health — the leading professional organization for transgender health care. Like the other three expert witnesses called by the state, Levine has spoken in court in defense of several laws similar to North Dakota’s.

Levine said adolescents cannot consent to gender-affirming care, so it should be limited to adults. He also said therapy is the superior course of action for treating gender dysphoria. 

Levine said he knows of many adults who have received gender-affirming care but do not appear to have benefited from it. 

“I’ve had the occasional adult who I think has prospered from trans-affirmative care,” he said.

Levine also said he believes that most adolescents who believe they have gender dysphoria are really suffering from other psychiatric conditions. He said this explains the sharp increase in young people who are seeking gender-affirming care over the last 15 years.

Jan Conlin, an attorney for the plaintiffs, indicated Tuesday there are fewer than a dozen kids in North Dakota who have sought gender-affirming medical care. 

“Would that surprise you?” Conlin asked Levine.

“I guess it would,” Levine replied.

Levine, like the other three witnesses who testified for the state, stressed that the medical research on gender-affirming care is nascent and unsettled. 

Levine said that most children who believe they’re transgender later come to identify with the sex they were assigned at birth. He said he acknowledges that the North Dakota transgender health care ban may be a source of distress for adolescents who depend on the treatment, but that he’s skeptical that it would cause them to suffer significantly.

“Every crisis doesn’t necessarily harm somebody,” he said. “It’s not necessarily the end of the world for that child. It may, in fact, be the beginning of a chance to rethink this whole matter.”

Witness disputes reliability of North Dakota doctors who treat transgender minors

Casas, the pediatric endocrinologist, last week testified that one of his patients attempted suicide after learning after the health care ban.

The plaintiffs on Tuesday brought back Gabriela Balf, a psychiatrist with experience treating adolescents with gender dysphoria, as a rebuttal witness.

Balf acknowledged that there is limited research exploring the use of transgender health care for minors, she said. She said it is very difficult to conduct top-tier studies like randomized control trials on children because it’s unethical.

“We simply cannot do these kinds of trials with kids,” she said. “I would like to put to rest once and forever this idea that we’re not doing this because we’re lazy.”

Still, Balf said that the bulk of research suggests the transgender adolescents have benefited from gender-affirming care. She also said that some of the research cited by the defense’s witnesses has been discredited.

Balf questioned why the state thought it necessary to adopt the health care law when it’s never bothered to regulate other areas of medicine.

“I find it so discriminatory to have so much scrutiny of this condition and others, they are just swept under the rug,” Balf said.

She said a couple years ago, a scientific review noted that more than 600 medications are prescribed off-label to children.

“And yet, they’re given to kids,” Balf said. “And nobody seems to be very bothered about it.”

Over the course of the trial, Casas, Balf and two other doctors with personal experience treating transgender adolescents testified that in some cases, gender-affirming medication is necessary for patients’ health and happiness.

Two teenage patients of Casas testified last week that the treatment turned their lives around. Both said they also receive therapy, but that the therapy would not be enough to effectively treat their gender dysphoria.

There are only two pediatric endocrinologists in North Dakota: Casas and Amanda Dahl, who is Casas’ clinical practice partner. Casas said he and Dahl both follow the same standards for administering gender-affirming treatment care. No adolescent can receive gender-affirming care without a diagnosis of gender dysphoria, he said. Patients and their families are also informed of what to expect and the risks of the treatment.

The gender-affirming care ban passed North Dakota’s Republican-dominated Legislature with more than two-thirds approval in each chamber. 

The ban contains an exemption for children who were receiving treatment before it went into effect. However, even adolescents who fall under the exemption are no longer receiving the care in North Dakota.

Casas testified he no longer provides gender-affirming care to any minors in North Dakota, including patients he saw before the law was enacted, for fear of prosecution. Those patients must travel to Moorhead, Minnesota, to see him for treatment.

The law makes it a class A misdemeanor to administer gender-affirming treatments like puberty blockers or hormone therapy to a minor. Anyone found guilty of doing so could face up to 360 days in jail, fines of up to $3,000 or both. Medical professionals also fear a violation of the ban could jeopardize their medical licenses, according to records filed in court.

The law also makes it a class B felony to perform transition-related surgery on a minor. Experts have testified in the case that medical professionals do not perform such surgeries on minors in North Dakota, and did not before the ban.