Colleen Kuhn’s office is filled with subtle rainbows. The books on the shelves are color-coordinated, a framed photograph of a rainbow arching over Utah’s Lake Blanche covers one wall and little wooden dinosaurs painted the colors of the transgender and LGBTQ pride flags perch on the window sill.
Kuhn, an adolescent psychologist specializing in gender, said the color strewn throughout the room is intentional.
“I wanted this to feel like a comfortable, welcoming, affirming, safe space,” said Kuhn, who is nonbinary.
The majority of Kuhn’s patients are navigating their own gender identity. They use play therapy, games and more interactive measures to help kids express their feelings.
For Kuhn, watching patients unravel the knots of gender expression is a rewarding experience.
“I have numerous patients that I can tell you about, the amazing evolution of them coming into their authentic gender self,” they said.
But the evolution Kuhn speaks to recently got harder.
Utah was the first of several states in 2023 to ban gender-affirming care for transgender youth. Within the first two weeks of the 2023 Utah Legislative Session, Gov. Spencer Cox signed the law that permanently and immediately prohibited transgender people younger than 18 from undergoing gender-affirming surgery, such as a full mastectomy, or “top” surgery, or accessing hormone therapy like puberty blockers or testosterone.
As a nonbinary person, Kuhn medically transitioned in their 40s, experiencing first-hand the importance of accessing gender-affirming care.
So when SB16 went into effect, Kuhn said they were devastated.
“They just have no idea what they've done. They have no idea what's going to happen. The increase in depression and anxiety and suicide attempts and suicide completions,” Kuhn said. “I felt like signing that bill was signing death certificates.”
If doctors do provide those services to minors, they could lose their medical licenses and even face criminal charges. Minors who receive gender-affirming care can also sue their provider over it until age 25.
The only exception is for minors who were diagnosed with gender dysphoria before Jan. 28, 2023. Even then, the patient needs to have the diagnosis for at least six months before they can begin hormone therapy, and surgery is still not allowed until age 18.
On the Senate floor, Republican Sen. Mike Kennedy — a family doctor and bill sponsor — argued it was necessary to restrict hormone therapy until there was conclusive evidence that the treatment didn’t cause irreversible physical harm to a child’s body.
At a March physician board meeting with the Utah Department of Professional Licensing, Kennedy said he was “heavily recruited and essentially mandated” to limit gender-affirming care for trans youth “because the Legislature could not bring themselves to a consensus” on the topic.
He added the law sets up a framework for how to care for transgender patients.
“There was no regulation as to transgender health care prior to SB16,” Kennedy said. “Anybody could hold themselves out as a transgender minor health expert and perform any care that they wanted to within the bounds of their professional expertise.”
The new policy left doctors to identify alternative ways to care for their trans youth patients.
Dr. Nikki Mihalopoulos is an adolescent medicine physician at the University of Utah and heads the Gender Management & Support Clinic at Primary Children’s Hospital. Speaking in a personal capacity, she recognized the intention behind the bill.
Mihalopoulos said she met with Kennedy in 2020 about the bill’s concept. She said Kennedy informed her that he wanted to ensure “providers who were treating transgender children had the expertise [and] the knowledge to provide the best possible care” without causing harm.
“Which sounds pretty good when you say it that way,” she said. “But when it gets written down and manifests as SB16, it actually becomes harmful.”
Kennedy told physicians in March that he does see transgender patients but “refer[s] them to those [doctors]” who he believes are qualified in the field.
Until recently, Mihalopoulos would be the doctor to prescribe young trans patients puberty blockers and hormone therapy. That decision didn’t happen quickly.
“We don't want to rush the process because figuring out who you are sometimes takes some time,” she said.
Kuhn said that it’s not unusual for them to meet with a minor patient for over a year before referring them to someone like Mihalopoulos for hormones. Now, Mihalopoulos can’t prescribe these medications to trans youth. So she’s been looking outside of Utah.
“What I'd like to do is figure out how to expedite care in another state. Once someone has undergone an evaluation in our clinic to talk about options and make a recommendation so that they can be seen sooner if there is the capacity to see them in another space,” she said.
But that has already proven to be difficult. Mihalopoulos said the physicians and transgender health specialists she’s spoken with in other states have a six to nine month waiting list for their own in-state residents.
A backlog of patients exists in Utah, too. Mihalopoulos said the GeMS clinic sees about 30 new patients a month. There are more Utah youth that want to be seen, but she said the clinic doesn’t “have the capacity to see them all quickly” because “there are so few providers.”
Pediatric plastic surgeon Dr. Dana Johns completed her medical residency at the University of Utah and has extensive experience in transgender health care.
“I was fortunate enough to train at Utah and have gender-affirming care be a part of my surgical training,” she said.
She’s one of the only surgeons at Primary Children’s Hospital who would perform top surgeries on transgender teens.
Johns said “it’s like watching a flower bloom” to observe the transformation she sees in patients who go through top surgery. Prior to surgery, she can see the physical “burden their body carries.” After, “they’re a different human, hands down. You can’t witness that before and after and have any doubt about what you’re doing and if it’s right.”
Johns said she finds the entire law to be isolated. There are many cosmetic procedures she’s allowed to do under parental consent, like reconstructing a 15-year-old’s nose because they are uncomfortable with the size or removing extra breast tissue from a teen male who identifies as a male because of bullying. But she isn’t allowed to perform that same surgery for a transgender male.
“None of these things are coming into question,” Johns said. “So if you're going to tell me you're not targeting a population, you can't.”
Before the law was even signed, she partnered with other providers to compile a list of people in surrounding states who could give her patients an avenue to care. She is also trying to find a way to help her patients in Utah.
“We can't operate until they're 18. But maybe if we start seeing them at like 17, even though it might be a year or two before we can operate, at least we see them and they feel seen and they feel like it's going to happen. And it can give them some kind of modicum of hope to hold on to,” Johns said.
Kuhn, Mihalopoulos and Johns said they will abide by the law. But all three providers are clinging to hope that the law will be challenged in court. Sen. Kennedy said on the Utah Senate floor that he would bet every dollar in his bank account that the law will be litigated.
The American Civil Liberties Union of Utah announced their intent to sue. No lawsuit has been filed yet.
In the meantime, all three providers say they will keep fighting for their patients to receive the care in their home state.
To Mihalopoulos, that matters.
“To watch them go from feeling uncomfortable and uncertain in their body to really becoming their authentic self and coming in and sharing a poem that says, ‘I love myself so much. Thank you for helping me to become who I am.’ It's incredible.”
