“Fear of discrimination can lead individuals to forgo care, which can have serious negative health consequences," said HHS Secretary Xavier Becerra. “Everyone — including LGBTQ people — should be able to access health care, free from discrimination or interference, period.”

It marked the latest step by President Joe Biden to advance the rights of gay and transgender people across society, from military service, to housing, to employment opportunities.

Becerra said in a statement the policy shift will bring HHS into line with a landmark 6-3 Supreme Court decision last year in a workplace discrimination case, which established that federal laws against sex discrimination on the job also protect gay and transgender people.

Despite that ruling, the Trump administration proceeded to try to narrow the legal protections against health care discrimination, issuing rules that narrowly defined “sex” as biological gender. A federal judge had blocked those rules from taking effect, although Trump administration officials argued that as a legal matter health care discrimination was a separate issue from the employment case the Supreme Court decided.

Monday's action means that the HHS Office for Civil Rights will again investigate complaints of sex discrimination on the basis of sexual orientation and gender identity. Hospitals, clinics and other medical providers can face government sanctions for violations of the law.

The Biden administration action essentially restores the policy established during the Obama years. The Affordable Care Act included a prohibition on sex discrimination in health care but did not include the term “gender identity.” The Obama administration interpreted the law as shielding gay and transgender people as well. It relied on a broad understanding of sex shaped by a person’s inner sense of being male, female, neither or a combination.

Behind the dispute over rights for transgender people in particular is a medically recognized condition called “gender dysphoria” — discomfort or distress caused by a discrepancy between the gender that a person identifies as and the gender assigned at birth. Consequences can include severe depression. Treatment can range from gender confirmation surgery and hormones to people changing their outward appearance by adopting a different hairstyle or clothing.

Under the Obama-era rule, a hospital could be required to perform gender-transition procedures such as hysterectomies if the facility provided that kind of treatment for other medical conditions.

LGBTQ groups say explicit protections are needed for people seeking gender transition treatment, and even for transgender people who need care for illnesses such as diabetes or heart problems.

More than 1.5 million Americans identify as transgender, according to the Williams Institute, a think tank focusing on LGBT policy at the UCLA School of Law. A bigger number — 4.5% of the population— identify as lesbian, gay, bisexual or transgender, according to Gallup.

Professional groups like the American Medical Association, along with civil rights organizations, have supported health care protections for gay and transgender people, while social and religious conservatives sought to narrow their scope.

HHS is a traditional battleground for conflicts over social issues. During the Trump administration the department clearly bent to the will of conservatives. Other Trump policies applauded by the right restricted abortion referrals and broadened employers' ability to opt out of providing birth control to women workers covered by their health plans. Under Biden, the policy pendulum has been swinging back in the opposite direction, as officials unwind actions taken in the Trump years.

One of Biden's first steps after taking office was a Jan. 20 executive order on combating discrimination on the basis of gender identity or sexual orientation. The new president directed every executive branch agency to examine what it could do to combat such discrimination.

Biden quickly followed that up with another order reversing a Trump-era Pentagon policy that largely barred transgender individuals from serving in the military.

And earlier this spring, the Department of Housing and Urban Development withdrew a Trump policy that would have allowed taxpayer-funded homeless shelters to deny access to transgender people.

At HHS, Biden's term has seen the Senate confirmation of Dr. Rachel Levine to be assistant secretary for health, a senior position that involves oversight of public health initiatives, HIV/AIDS, women's health and minority health, as well as other areas including research protections. Levine, formerly Pennsylvania's top health official, is the first openly transgender person to be confirmed by the Senate.

The GOP-backed ban on transgender students playing women and girls' school sports is awaiting Gov. Ron DeSantis's signature. Democrats and LGBTQ advocates say the move could result in lawsuits.

Governors in six states have already signed similar bans into law, and a seventh state has similar restrictions via executive order. Idaho's law is already facing a challenge. Proponents of the ban say people assigned male at birth have a physical advantage over those assigned female at birth. Meanwhile, Democrats and LGBTQ advocates like Equality Florida's Gina Duncan say the ban is harmful to young transgender people.

"It is overtly discriminatory, and as called out by the Biden administration, this bill is illegal, discriminatory, and a violation of Title IX," Duncan says.

Adria Lynn Silva is a Title IX attorney. She says there's legal precedent prohibiting discrimination against transgender students. She points to a case in Virginia where a transgender boy was prohibited by his school board from using the boys' restroom.

"The language that the court used is that when you discriminate against somebody because of their gender expression or their gender identity, it's the same kind of segregation that creates harmful stigma, and they made an analogy to the same kind of racial discrimination that students felt when students were forced to use separate bathrooms or restrooms, which was one of the issues in Brown versus the Board of Education," Silva says.

The court ruled in favor of the transgender boy, Gavin Grimm. As for Florida's transgender athlete ban, Silva says the Republican argument relies on stereotypes.

"You can't just make up a bunch of—generally—that you know girls and women athletes are going to be at a disadvantage if you allow somebody who identifies as transgender to compete on the women's team or the girls' team. That's the kind of sex stereotyping that Grimm prohibits," Silva says.

The National Collegiate Athletic Association (NCAA) paves a way for transgender women and girls to compete on female teams. They have to undergo hormone therapy, which suppresses their testosterone. The Florida High School Athletic Association (FHSAA) also allows for transgender athletes to compete. Since 2013, 11 transgender students have applied for and been allowed to play on teams that align with their gender identity. But Florida's new law would do away with those policies in the state.

Attorney Dean LeBoeuf says challenging the ban will be difficult. He says the strongest case would be one where a transgender student meets the FHSAA or NCAA criteria to compete on female teams.

"Then, of course, they would have to say that they applied and showed that they applied and then that they were not allowed to compete despite meeting that criteria and I think that would give them standing to be able to bring a claim," LeBoeuf says.

But he says establishing that the ban discriminates on the basis of sex is going to be difficult because the case law is still evolving around that area.

"You know that whole area is evolving even in the employment sector. I think that it's changed a lot. But historically, that wasn't even a basis to bring a claim historically for employment discrimination, gender identification suits, so it's an area that's evolving in the law, so it's not going to be in my mind easy, it would be clearly an uphill battle," LeBoeuf says.

LeBoeuf says another hurdle a plaintiff would have to overcome is time.

"Let's just say hypothetically they're a senior in high school and they want to compete on, let's just say a tennis team, assuming that there's a relatively short season for that and so by the time they were denied their opportunity to do that and ended up getting an injunction from a court it may be too late for them in terms of that season to be able to compete," LeBoeuf says.

For now, LGBTQ advocates are urging DeSantis to veto the ban.

Throughout much of her childhood, P. felt like something was off. But she didn't know exactly what.

"I felt at odds with myself," the Decatur resident recounted. "Almost like my physical body was trying to push me in one direction but I wanted to go another."

The breakthrough moment came on a family vacation in 2017, when she read a National Geographic cover story about Avery Jackson, a pink-haired 9-year-old who is transgender.

"I remember reading her story at like 1 in the morning, sitting in the Airbnb thinking, 'oh my God, that sounds like me,'" said P., now 16.

There are no simple paths for transgender children, whose gender identity does not match the sex they were assigned at birth.

Acceptance is not a guarantee. Getting teachers, classmates and school administrators to call them by the correct names and pronouns can be a fight. Arrangements often need to be made for places as basic as locker rooms, school bathrooms and camp bunks — where bullying or traumatic moments could occur.

Many local parents and teens are even more on edge as upwards of 30 states this year have considered — and several have passed — legislation that would affect transgender youths and their support systems. Arkansas took the most aggressive step in April, when it became the first in the country to criminalize physicians who help children under 18 transition genders.

Much of the legislative action is taking place across the South, including Georgia, where two sets of bills were introduced at the Capitol this year and could be picked up again when the General Assembly reconvenes in January.

Such laws would limit the options available to teens like P., who rely on hormones to help align their bodies with their gender identities. Medical associations like the American Academy of Pediatrics and the American Psychological Association say such treatments can be life saving for a marginalized population that's already at a high risk of suicide and depression. Supporters of the proposals say they protect children from making lasting medical decisions before they are old enough to understand the consequences.

The Atlanta Journal-Constitution agreed to identify two minors in this article by their first initials to protect the privacy of the children and their families, who feared being targeted by opponents of transgender rights and spoke on condition of anonymity. One teenager, with his parents' blessing, chose to have his full name published.

Lawmakers zero in

Georgia's transgender community is small yet significant. A 2016 study from the Williams Institute at the UCLA School of Law estimated roughly 55,650 people in Georgia, or 0.75% of adults, identified as transgender, fourth among U.S. states in percentage terms. Among high school students, the Centers for Disease Control and Prevention estimated almost 2% nationwide identified as trans in 2017.

Even as public support for transgender rights has grown, trans kids increasingly have found themselves on the front lines of the nation's culture wars over the last five years.

The first skirmishes involved restroom access. North Carolina's infamous "bathroom bill," passed in 2016 and partially repealed a year later, drew national headlines and boycotts, while closer to home, schoolboards from Decatur to Pickens County contended with the issue.

More recent proposals would require transgender kids to compete on sports teams that correspond with their gender assigned at birth rather than the one with which they identify. Supporters, which include socially conservative and religious organizations such as Alliance Defending Freedom, Duluth-based Faith and Freedom Coalition and Georgia Baptist Mission Board, have argued girls who aren't transgender could be crowded out of sports teams and scholarship opportunities.

Other bills floating around state legislatures would create criminal penalties for doctors who help minors transition by performing gender confirmation surgery or prescribing puberty blockers or hormones.

Blockers delay puberty to give children more time to decide next steps without their bodies developing features they'd want to change later, such as facial hair or breasts. Their effects are reversible, while those from hormone treatments partially are not. The Endocrine Society recommends that doctors wait until a patient has "sufficient mental capacity to give informed consent," usually by age 16, to prescribe estrogen or testosterone. Surgery, meanwhile, is exceedingly rare for children under 18.

Proponents of restrictions say they're trying to protect children, and particularly teenagers, from making permanent changes to their bodies while they aren't emotionally mature.

The government sets a minimum age for getting tattoos and buying cigarettes, and life-altering medical care should be no different, said state Rep. Ginny Ehrhart, R-Powder Springs, the lead sponsor of Georgia's version, which would make it a felony punishable by up to 10 years in prison for doctors assisting in a minor's transition with blockers, hormones or surgery.

A dozen southeastern states have considered sports or medical care proposals this year, according to the Campaign for Southern Equality, despite legal threats from organizations like the ACLU and boycott threats from the NCAA.

Arkansas, Mississippi, Alabama and Tennessee have already signed transgender sports legislation into law. And a dozen states around the country are considering an Arkansas-style ban on blockers, hormones or surgery for minors.

Dr. Izzy Lowell's Queer Med clinic in Decatur would be directly affected by the latter. It serves transgender people in nearly a dozen mostly southeastern states. About 1 in 8 of its roughly 2,000 patients are under 18.

"There's no medical reason for this bill," Lowell said. "There are very significant, very real risks of not giving hormone therapy. In many cases that's a very real risk of harm, both self-harm and harm from others."

Six southern states are mulling proposals that would go even further: penalizing parents who help their children medically transition.

Family matters

LGBTQ advocates argue that such legislation is inhumane, since research shows just how life saving so-called gender-affirming support, both from family members and medical treatments, can be. More than one in three transgender high school students have attempted suicide, at least four times higher than among non-trans students, according to recent CDC data.

But rates drop by more than 45% when a family is highly accepting of a young person's gender identity, according to The Trevor Project, an LGBTQ suicide prevention group. Use of puberty blockers and hormones are similarly associated with decreased behavioral and emotional problems.

For P., the physical changes were slow to come when she first started taking hormones two years ago. But she immediately felt a mental shift.

"It was kind of this innate psychological thing of like, 'I'm getting there,'" she said. That "slowly but surely I'm on the right track."


Her parents, Michelle and Dave, admitted they knew little about transgender people when P. came out to them at 14. They wanted to be supportive, but also quietly wondered whether it was just a phase. As P. began to transition socially and then physically, the couple quickly realized she wouldn't change her mind.

They saw how elated she was the first time she wore a skirt outside the house at Oakhurst's Porchfest, and how she blended right in at a Pride festival they stumbled across while on vacation in Vienna, Austria.

"As a parent, you want to shield your kid from all the dangers of the world as long as you can," said Dave, who asked that the AJC withhold his family's last name to protect his daughter's privacy. "But you also have to recognize that this is the path that they're going down and this is how they can live as their authentic selves."

Peter Isbister leads the metro Atlanta chapter of the support group TransParent, which aims to help parents become "confident caregivers and advocates" for their trans kids. He said there's no universal experience for the parents who show up at his meetings. Some mourn for the little boy or girl they initially raised, while others are quicker to adapt and eager to find ways to support their child.

"Like so many things, it is completely individual," Isbister said.

In worst-case scenarios, parents become estranged from their children. Custody battles have been waged when one parent objects to a child's transition. One such fight over a 7-year-old in Texas became a cause célèbre of the conservative media in 2019, drawing rebukes from prominent voices including U.S. Sen. Ted Cruz and Donald Trump Jr., and helping inspire legislation in at least three states, including Ehrhart's bill in Georgia.

It can be especially hard for families outside of metro Atlanta where LGBTQ people aren't as visible. Lowell said she recently saw one patient who'd been turned away by nearly a dozen other physicians.

LGBTQ health is not taught comprehensively in medical schools today, according to Lowell, and even in metro Atlanta the system of primary care doctors, therapists and endocrinologists who provide gender-affirming care resembles a patchwork.

A few years ago, Suzanne Haerther of Atlanta spent hours on the phone with her insurance company trying to find a local therapist who could help her transgender daughter, who was then in high school. Even many of the counselors specializing in LGBTQ issues told her they weren't experienced treating transgender patients.

"As a parent you have a child who's going through a traumatic experience and you're trying to find somebody who can professionally help them," Haerther said.

Leaving Georgia

At the statehouse, at least one prominent Republican has indicated he's not interested in wading into the fight.

"Sometimes we have issues that come along that are almost solutions in search of a problem," said House Speaker David Ralston, R-Blue Ridge, when asked about the sports bill in April. He hasn't weighed in on Ehrhart's bill, but the measure did not advance past the committee stage last session.

Despite that, some young transgender Georgians have cast their gaze outside the state as they decide where they want to build their futures. Even without passage of the legislation, they feel like they'd be more welcome elsewhere.

P., a high school junior, is looking at colleges outside the South. Sam Schexnyder, a 16-year-old from Decatur, didn't wait until graduation.

Within weeks of coming out as transgender in eighth grade, Schexnyder witnessed his local schoolboard get embroiled in a fight over its bathroom and locker room policies. So he was blown away when, on a trip to the West Coast, he saw how much more accommodating other states were to trans people.

He begged to move in with his aunt in Seattle, and upon starting school there almost two years ago, Schexnyder marveled at all of the gender-neutral bathrooms and multiple options on enrollment forms for pronouns. Teachers were used to trans students — there are a half-dozen in each grade in his new school — and there's no risk of his classmates accidentally calling him by his old name or pronouns since they never knew him pre-transition.

"It's just, it's wildly better here," said Schexnyder, a grin sprouting across his blond, bearded face during a recent video call. "I think that's definitely the most important part of transition, just to know that other people are going to help you along in that period of your life where you're figuring things out and trying to become a better version of yourself."

Isbister, the head of TransParent, and his wife Robyn had resolved to provide that kind of support for their child, E., after he announced at 5 that he wanted to live as a boy. The proclamation didn't come as a surprise. E. had signaled for years that he didn't identify as a girl, eschewing dresses and at one point asking his family to call him Franklin for a month.

In the fall of 2018, the Decatur couple emailed their friends, neighbors and family members — pretty much everyone they could think of who regularly crossed paths with their children — with a request to call E. by his new name and pronouns.

"First and foremost in our minds these days is our ability to provide a safe and loving community for E. so that he does not have to grapple with hatred, shame, societal stigma, or feeling 'less than' at such a tender age," they wrote.

They know they can't shield their son, now 8, from the world forever, but they hope to insulate their happy-go-lucky child for as long as they can. Both parents are lawyers, and they say if Georgia lawmakers limit options for transgender minors, the family is willing to travel out of state to get treatment or fight such a statute in court.

"He has known from the beginning who he was," Robyn said. "It would be a crime to have him living as a girl."

Why we didn't fully name some people in this article:

It is rare for The Atlanta Journal-Constitution to not fully name people it quotes, because identity is an important factor as readers judge the credibility of information. Sometimes, after careful deliberation, the AJC makes exceptions. Several parents interviewed for this article wanted to protect their child's privacy, citing their age and the sensitivity of the topic. The AJC decided it was important to share their experiences while safeguarding minors. Also factoring into the decision: Trans youths suffer higher incidences of bullying, depression and suicide, according to studies. In this article, minors in two cases are identified only by their first initial and some parents are not fully named to protect a minor's identity. The reporter communicated with families several times through a combination of phone and video calls, emails and texts. The reporter, together with an editor, verified family details through online public documents and social media posts. Two editors also reviewed emails and texts between the reporter and families.

Today, the Business Coalition for the Equality Act announced it has grown to include more than 400 major U.S. corporations (including dozens of Fortune 500 companies) calling for the urgent passage of the Equality Act — federal legislation that would modernize our nation’s civil rights laws by including explicit protections for LGBTQ people, as well as improve protections for women, people of color, and people of all faiths. The announcement signals unprecedented support for the Equality Act among America’s business leaders, who join a majority of Americans, hundreds of members of Congress, hundreds of advocacy organizations, and more than 60 business associations — including the U.S. Chamber of Commerce and the National Association of Manufacturers — in endorsing the federal legislation.

The 416 member companies of HRC’s Business Coalition for the Equality Act represent a major swath of America’s economic engine, with member companies overseeing business operations in all 50 states, company headquarters spanning 33 states and a combined $6.8 trillion in annual revenue. The 416 members of the coalition collectively employ more than 14.6 million people in the United States. The Business Coalition for the Equality Act is believed to be the largest business coalition to ever come together to speak out in support of legal LGBTQ equality. The largest former effort was the business amicus brief for marriage equality, which included 379 businesses.

We are seeing growing support from business leaders because they understand that the Equality Act is good for their employees, good for their businesses and good for our country. Employers care about their employees’ ability to rent an apartment, send their kids to school, visit the dentist, and pick up the groceries free from discrimination. They realize that when LGBTQ employees and their family members are protected in their daily lives, it makes them more secure and confident in their jobs, and also more productive. Thank you to every company that is speaking up and advocating for the passage of the Equality Act. It’s time for the Senate to listen to the business community and the public and pass this long overdue legislation.

Alphonso David, Human Rights Campaign President

The Equality Act ensures everyone in America, including LGBTQ people, are protected from harassment and discrimination in all areas of life. Currently, even if an LGBTQ person works for a company that provides clear non-discrimination protections and inclusive cultures, that employee and their family members can still experience discrimination in other areas of life and have no legal recourse. In the majority of states — 29 states in total — that lack explicit nondiscrimination protections, these employees can be denied healthcare, loans, housing, and basic goods and services because they are LGBTQ.

The business community’s support reflects the broad and overwhelming support for the Equality Act in communities nationwide. New polling from Hart Research Associates found that 70 percent of Americans (including 50 percent of Republicans) support the Equality Act. Hundreds of members of Congress and more than 600 organizations, including the nation’s top leaders in civil rights, education, health care, and faith organizations have also endorsed the legislation.

Corporate endorsements for the Equality Act have more than doubled since the Equality Act passed the U.S. House in 2019.

Business Support for the Equality Act

American’s mission of taking care of people on life’s journey includes making the case for greater equity and inclusion, two of our company’s core values that are also critical to our success. That’s why we’re proud to join with the Human Rights Campaign and this broad coalition of businesses in support of the Equality Act, a measure that would protect Americans from the kind of discrimination, harassment and unequal treatment that runs counter to our purpose. American has proudly stood with the LGBTQ community for decades and will continue to advocate for full inclusion, equity and protection under the law, because all of our team members and customers deserve to feel welcome and safe.

Molly Wilkinson, Vice President of Regulatory Affairs and PRIDE EBRG Executive Sponsor

Levi Strauss & Co. is proud to support the Equality Act. We have a long history of supporting equal rights for the LGBT community, from being the first Fortune 500 company to extend health benefits to unmarried domestic partners more than 20 years ago, to being the only California business in 2007 to file an amicus brief with the California Supreme Court in support of same-sex marriage. The time has come in this country for full equality for the LGBTQ+ community. Ensuring fairness in our workplaces and communities is both good for business and simply the right thing to do.”

Anna Walker, Vice President, Public Affairs

Dow has been a proud supporter of the Equality Act since it was first introduced; and we continue advocating for the full inclusion of the LGBTQ+ community in the eyes of the law. Ensuring equality and opportunity for all is not only the right thing to do as a matter of human decency, it is good for society and business.

Louis Vega, President, Dow North America and VP Government Affairs & Advocacy, North America

A workforce that reflects the diversity of today's society drives new ideas and innovation. At IBM, we seek to hire the most talented individuals regardless of their gender identity, sexual orientation, religion, or other personal characteristics. We also believe that equal protections should extend beyond an employer's four walls, which is why IBM stands with HRC in endorsing the Equality Act. It's time that civil rights protections be extended to LGBT+ individuals nationwide on a clear, consistent, and comprehensive basis.

Carla Grant Pickens, Global Chief Diversity & Inclusion Officer

At Marriott, we believe that every individual, including those in the LGBTQ community, should feel welcome, safe and respected when they enter one of our properties. As a global hospitality leader, our principles of non-discrimination extend to all travelers, and include sexual orientation and gender identity. That is why we are proud to join with the Human Rights Campaign and support passage of the Equality Act, to help ensure equality under the law as well as under our own roof.

This Tuesday, Missouri Senate results show that the controversial transgender athlete bill is unlikely to pass in the House. The bill earned its controversy as a result of the long-winded debate regarding the morality of allowing transgender individuals to participate in the sport of the gender they identify as.

“I think it’s good – trans women being in womens’ sports – I wouldn’t put a woman in a man’s sport with a bunch of men. But it depends on weight – you wouldn’t put a woman in boxing who’s 5’2 with a man who’s 5’7. Especially if they’ve transitioned and gone through hormone therapy,” William Barret (’23) says regarding trans-identifying people participating in sports. In certain sports, differences in weight and height will differentiate who plays in what regardless of their sex at birth (i.e. different weight classes in wrestling.)

On Tuesday, the House debated an amendment sponsored by Republican Chuck Bayse that essentially forced transgender students to participate in the sport aligned with their sex at birth if they so chose to play a sport. For example, if an AFAB (assigned female at birth) student who identified as male wanted to play a sport, they would be forced to play on a female team. This amendment proposal was attached to an unrelated education bill that passed with a 100-51 vote.

The major controversy with allowing transgender people to participate in the sport that aligns with the gender of their choosing is the physical differences between the male and female bodies. Regardless of how someone may identify, their physical ability may put them at an unfair advantage or disadvantage in a certain sport. This changes with trans-identifying individuals who have gone through hormonal and surgical transitioning, but as it isn’t legal for minors to medically transition without parental consent in the state of Missouri, the argument still holds.

“Imagine a 6-foot tall man who identifies as a woman, in a women’s sport. It’s just kind of unfair,” Ethan Wood (’22) said about the matter.

Like many controversial issues, the debate has no real right or wrong answer. It’s highly dependent on the situation – what sport they’re participating in, how far they are into their transition, and several other factors need to be considered in order to determine the actual morality of the situation.

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