For All the Young Trans Folks

Riley Smith, MD

Fam Med. 2024;56(1):52-53.

DOI: 10.22454/FamMed.2023.514120

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A 14-year-old sits across the exam room from me, his brightly colored hair contradicting his weary expression. “What happens if I have to stop testosterone?” Felix asks. His newly deepened voice cracks, and I can tell that he is trying not to cry. I am not sure whether he can tell that I am doing the same.

Over the past few months, this conversation has played out over and over in my clinic and in clinics across the nation. While legislators sit in sterile office buildings writing laws whose impact they cannot begin to fathom, I am alongside my patients in a field of uncertainty, fear, and despair. State after state has passed legislation restricting the ability of transgender youth to access gender affirming care. I was raised and practice medicine in North Carolina, the latest state to pass such a ban. A ban on health care that we know is safe, effective, and evidence-based. Health care that is supported by every major medical organization in the United States. Health care that is lifesaving in the truest sense.

When I met Felix, he graciously shared his story with a maturity that exceeded his young age. Struggles with his identity, the disconnect he experienced between aspects of his body and those he longed to have—a deeper voice, a flatter chest. His parents sought to be supportive and had many questions. At their core, they just wanted a child who was happy and healthy, and to make informed decisions about their child’s care. “What changes would these medicines cause? What if this is just a phase? Will this make his life more difficult?”

I became a family physician because, like many of us, I was drawn to the idea of building relationships to improve the health of individuals and communities throughout the life span. As a transgender man, I have experienced firsthand the stark disparities caused by discrimination and transphobia, and I have always known that caring for my community would be integral to my career. It would be naïve to think being an openly transgender doctor providing gender affirming care in the South was always going to be easy, but I never anticipated the politicization of transgender identity and health care we have seen recently. Through years of providing gender affirming care, I have experienced the absolute privilege and honor of bearing witness to one of the most profound, life-changing processes that a person can go through. Now, listening to legislators and media outlets spew hateful and false narratives about that process, and seeing the effect that has on my patients, leaves me outraged.

My young transgender patients are creative, thoughtful, resilient, and remarkable in every way. I have cared for some of them for years and have seen the immense positive changes that gender affirming hormones bring. The 15-year-old living in a rural, conservative town who drove 2 hours to his appointments and, by starting testosterone, gained the confidence he needed to finish high school and attend college with a full scholarship. The 16-year-old who was so dysphoric about her body she had to turn the lights off to shower, but who started taking estrogen and eventually found the courage to join her school soccer team, where she thrived.

And Felix, who I met shortly after his suicide attempt, who told me he could not envision a future in which he was living as a happy, openly transgender man. Whose parents love him deeply and trusted my knowledge and experience enough to engage in thoughtful, open discussions and make the decision that felt right for their family. Who found a supportive therapist, started gender affirming hormones, and has gradually weaned off his antidepressants. Who grinned ear to ear showing me the peach fuzz scattered across his cheeks. Who is planning on becoming a marine biologist. Who would normally be stressing about typical teenage boy things—friend drama, grades, unrequited crushes—but instead spent his summer attending political rallies and trying to make sense of why the government wants to take away medication he credits for saving his life.

These are the stories and real lives of my patients, and I am grateful to be part of their journeys. It is the most incredible, beautiful, gut wrenching, and heartwarming part of my job as a family physician. Now, facing the greatest challenge of my career thus far, I must tell them that the future of their care is in the balance.

In North Carolina, we are fortunate that our law has an exception allowing for continuation of certain treatments in specific circumstances. Yet new patients are barred from starting treatment, and anxiety among existing patients remains high knowing that at any moment the exception could be eliminated, their care terminated. Patients in other states are less fortunate and have been forced to stop their medications or travel hundreds of miles out of state to access them. A handful of places have seen litigation successfully stall or overturn these blatantly discriminatory laws, and one can only hope that trend continues.

For now, though, we wait. And we advocate. And we support one another. And we remind these kids that they are cherished, and celebrated, and that their lives are invaluable.

As a physician dedicated to providing the best possible care to my patients, I feel like I’ve been kicked in the stomach and the exam room is getting smaller by the second as emotions wash over. I am overwhelmed with pride at how much Felix has grown over the past few years, his courage through such adversity. I am furious for him, for all my patients and others across the country. And I am deeply saddened at the injustice of it all, at the cruelty we face for having the audacity to exist as our authentic selves.

I look Felix in the eye and take a deep breath. “I’m not sure what’s going to happen, but we will figure this out together. No matter what happens, I am your doctor, and I promise I am not going anywhere.”


The patient’s name and minor details have been changed for privacy.

I thank Drs Rita Lahlou and Rupal Yu for their feedback and unwavering support, and my transgender patients for allowing me the privilege of seeing their true selves.

Lead Author

Riley Smith, MD

Affiliations: University of North Carolina, Durham, NC

Corresponding Author

Riley Smith, MD


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