In the 26 states that ban health care for transgender teens, families may hit the road : Shots

DES MOINES, Iowa – In the future, Veronica sees herself in a big city.

“I like chaos and spontaneousness,” she says, and she doesn’t get much of that in her town surrounded by farmland outside of Des Moines. It’s slow and boring, she says. Matching rows of ranch houses line wide manicured streets, with SUVs parked in the driveways.

Veronica is 17. She has two more years of high school, then she can graduate and leave.

Hers is not just the usual adolescent wanderlust. This Iowa town has turned out to be a punishing place to be a transgender teenager. Her mom, Emily, has fought to change her name in the high school’s system. There’s no good option for which bathroom to use at school. Emily says neighbors and classmates have made cruel comments.

NPR has agreed not to use the family’s last name because of concerns for Veronica’s safety.

Iowa was part of a wave of states that passed laws related to transgender young people in the last two years. Currently, 26 states have laws on the books banning gender-affirming care for trans teens, and an estimated 110,000 trans teenagers live in states with bans in effect. Virtually all major U.S. medical organizations, including the American Medical Association and the American Academy of Pediatrics, support access to gender-affirming care for young people.

Iowa’s ban took effect in March 2023. Teenagers like Veronica who were in the midst of treatment had a few months to find an out-of-state option or stop their treatment.

“You never think, as a mom, ‘I can’t wait for my kid to grow up and leave the state,’ but that’s where I’m at right now,” Emily tells Veronica. It’s dusk, and they sit next to each other on the couch in the living room, surrounded by pillows. Thin-crust pizzas bake in the oven.

Emily’s voice catches: “I can’t wait for you to find your people, your support, your health care providers — everything you need. I want that for you, even if it’s far away.”

For now, the family is rooted in Iowa. Veronica is the oldest of four children – her parents are divorced and the kids are at their dad’s house in the same neighborhood half the time. All their grandparents live in Iowa, too.

So when Iowa’s gender-affirming care ban took effect last year, the family made a decision: Veronica and her mom would travel out-of-state every few months to keep getting the care Veronica needed.

Before dawn

The day of Veronica’s appointment in Minnesota starts before dawn. The residential streets are empty and dark. Cicadas chirp. Inside the house, Emily rushes around — making sure the younger kids have a plan to get to school, finding snacks and tea bags for the day’s road trip (she’s not a coffee drinker). By 6:44 a.m., she is at the wheel of her Jeep, with Veronica riding shotgun, headed for the interstate. They have almost four hours of driving ahead of them to get to the clinic.

Mom and daughter have catching up to do – where Veronica went when she snuck out a few months ago, how she talked her way out of a speeding ticket, what music to play in the car.

“It’s good,” her mom, Emily, says. “One-on-one is hard with four kids.”

Before Veronica even came out as trans, her mom sensed it. She remembers the specific moment — a transgender woman came and spoke to a class she was taking in 2017. “It was like I was hit by a bolt of lightning. I was like, ‘This is my child. I know this in my soul, in my heart,’” she remembers. “I was kind of just waiting to hear — I wasn’t pushing it, but I just knew.”

Years passed. Quietly, Veronica told her friends that she is trans in 2020, right as the pandemic was starting. “I kind of just held it between me and them during that time,” she says. “I wanted to be sure about it, you know? I didn’t want to jump into something that I wasn’t sure about and, like, tell everyone and then it’s like, ‘Oh, wait, never mind.’”

A year later, she was ready to tell her family members: “I was like, ‘OK, it’s been a year. Nothing’s changed. I don’t think it ever will.’”

She started eighth grade with her new name.

Even though her mom was expecting it, “when you came out to me, I had such a mix of emotions,” Emily tells Veronica. “I had this part of me that was like a cheerleader, ‘Let’s do this. Let’s get the flag in the yard.’ And then there is the mom part of me that felt so afraid of the targeting, the bullying and all these terrible statistics for this marginalized group — it was scary.”

She also had grief she needed to work through, she realized. “This is my oldest child, who’s also at the same time entering into this adolescent stage — so I am grieving my baby boy on a couple different levels.”

“Was that hard to hear?” Emily asks, and Veronica answers, “a little.”

A pause

Iowa is where Emily grew up, and where she moved to raise her own family. Then her home state started to pass laws affecting her family. In March 2023, the state passed a law dictating which bathroom students can use at school, and another banning gender affirming care for minors.

“We need to just pause, we need to understand what these emerging therapies actually may potentially do to our kids,” Iowa Governor Kim Reynolds told reporters right before she signed the bills into law. “My heart goes out to them. I’m a parent, I’m a grandmother, I know how difficult this is. This is an extremely uncomfortable position for me to be in. I don’t like it. But I have to do what I believe right now is in the best interest of the kids.”

When Iowa’s ban took effect, Veronica was taking puberty blockers. By that point, she had been out as trans to her friends for three years – out to her parents and siblings for two. She had also developed an eating disorder so severe she has gone to residential treatment twice.

Her mom Emily thinks these two challenges are related. “I wonder if — just knowing that you don’t want to use the bathroom [at school], and so then the way to avoid using the bathroom would be not to drink and not to eat during the day.”

Veronica shrugs. “I think they were just both happening simultaneously, separately,” she says.

Regardless, the past few years have been difficult for her. “Struggling with an eating disorder, on top of that, having gender dysphoria — it’s like two things just working together to ruin you,” Veronica says.

The “pause” in gender affirming care, as Iowa’s governor put it, was at odds with Veronica’s own biological timing. After the ban became law, the family got a message from the clinic explaining that they needed to stop Veronica’s gender care. Her doctors said if she couldn’t find a way to keep getting puberty blocker shots on time out of state, she would have restarted testosterone-driven puberty. That would have meant bodily changes like voice deepening, the growth of her Adam’s apple, facial hair, shoulder-broadening and more — some of which could be changed later with surgery or other procedures, some of which would be permanent.

Emily says her family’s path forward was always clear to her. “It was just never a thought that we wouldn’t continue,” she says. “As your mom I’m going to do everything I can to help you — I love you.” The idea that legislators are making medical decisions for her family “doesn’t seem right,” she says.

“I see it almost like a necessity,” Veronica adds quietly. “Not having access to it just seems terrifying, in a way.”

Their support network in Iowa helped. “I ended up with a list of resources, a couple of them, actually,” Emily says. “It was a Facebook, Zoom, call-to-action sort of thing.” She called around until she found a new pediatrician in Minneapolis who could take over Veronica’s gender treatment.

The first order of business was continuing puberty blocking shots, which she needs to get at an in-person appointment every few months. Then, in December of last year, her new doctor started her on hormone therapy. She started taking daily pills of estradiol, a type of estrogen, while she continued getting puberty blocker shots to keep her testosterone levels down. Since then, she’s essentially been going through female puberty.

September’s appointment was their third one in Minneapolis. Her mom thinks intervening now will help Veronica look more like someone who was born female when she’s older, which will hopefully make her safer — less likely to be the target of violence or discrimination for being a trans person.

Veronica is really happy with all of it. “I feel like it’s helped me feel a lot better about my body,” she says, “and made the eating disorder less prominent in my life.”

Emily says she’s noticed. “I just feel like your trend has just been up and up and up since you’ve started your estradiol,” she says. “You’re much more social and out and about with friends, you’re not home in your room as much. You seem happier. You’re not picking at your little brother all the time.”

“Feeling good?” “Definitely.”

More than three hours into the drive, the cornfields give way to warehouses and, eventually, high rises as we arrive in Minneapolis.

In the exam room, Veronica sits cross legged on the paper-lined exam table – her doctor starts by checking in with her – about her friends, her after school job, school. NPR has agreed not to name the clinic or doctor because of their safety and security concerns. He asks about her eating disorder recovery and whether she has enough support with that. He takes her blood pressure and other vitals.

“How is estrogen going?” he asks. “Great,” she beams.

He asks if she’s noticing effects — if the medication is doing things, “and those things are the things that we want and we’re feeling good?”

“Definitely,” she answers.

He asks about side effects, and she says she hasn’t noticed any. “Any change in overall goals?” he continues. “Still feeling like this is what we want, this is making life feel more tolerable, and feeling better in my skin, all that kind of stuff?”

“Oh yeah,” she says.

“That’s awesome,” he says. “That’s the hope.”

She heads to another room for a blood draw and the puberty blocker shot, which is a painful injection, given with a large-gauge needle into her leg. She asks to hold her mom’s hand for that part.

Veronica’s pediatrician says he’s pleased with how her gender care is going. “She is having the result that we hope she would have, which is feeling more peace with her body and being seen by people the way that she sees herself and wants to be seen,” he says.

Not all gender diverse teens want these kinds of medical interventions, he notes. “The medical piece of gender care is all driven by patient goals and embodiment goals, and the truth is, not everybody wants this kind of binary transition.”

In Veronica’s case, her vital signs and mental health have also improved since her appointment in the spring. “She’s doing well — in an ideal world, I would see her more often, but it is a burden [for her] to get here,” her doctor says.

Three of the four states bordering Minnesota have gender affirming care bans for youth — Iowa and North Dakota and South Dakota. Minnesota has gone in the opposite direction. Minnesota’s legislature passed a “trans refuge” law last year, and since then, hundreds of trans people and their families have moved to the state.

But not every family can move. Even traveling for appointments is difficult, with airfare or gas expenses, hotels, taking time off work.

For Veronica’s family, moving is not possible, but traveling is, although it’s grueling. Her doctor says that she is one of 15 patients he’s currently treating for gender dysphoria who travel in from out-of-state.

Her mom says part of what makes the travel tolerable is that Veronica will turn 18 next summer. “Then hopefully she can have more freedoms and have more access in Iowa, assuming that the laws don’t change before then.” At the moment, gender affirming care for adults is legal in Iowa.

“Long day”

After about 45 minutes at the clinic, Veronica is all done with the appointment. She and her mom stop at a Minneapolis pharmacy to pick up a six month supply of estrogen pills. They aren’t allowed to get the refills in Iowa because of the health care ban.

Then, it’s back in the car and back on the highway to go all the way back to Des Moines. They both seem relieved to have the labs done and refill in hand.

Before long, Veronica leans against the window and falls asleep. Along the highway, the “Welcome to Iowa” sign appears. Emily notes the tagline on the sign is “Freedom to Flourish.”

“Should have a little asterisk by it,” she murmurs.

More interstate, more cornfields, more hours. “It’s so boring, I’m just ready to be done,” Emily says. Veronica wakes up and bugs her mom to drive faster. She’s pleased her leg doesn’t hurt from the shot, but she thinks it probably will tomorrow.

Finally, they reach their exit. Veronica starts putting her sneakers back on. They pull into the driveway, and she bolts out of the car. She’s off to meet up with friends.

Emily climbs out of the car more slowly, gathering together cups and snacks. They’ve been gone for nearly ten hours and traveled 450 miles. “Long day,” she sighs.

Big picture, she says, it’s worth it. She’s happy to do it for her daughter.