North Dakota lawmakers seek to ban surgeries, treatment for transgender kids

Two separate proposals would establish criminal and civil penalties for performing gender-affirming surgeries and treatment on minors.

High school students march on the North Dakota Capitol grounds in February 2021 during a protest against a bill to limit transgender athletes' participation in K-12 sports.
Adam Willis / The Forum

BISMARCK — With North Dakota’s legislative session fast-approaching, conservative lawmakers are planning to introduce bills that would prohibit gender-affirming surgeries and treatments for transgender children in the state.

Newly elected Republican Reps. Lori VanWinkle and Brandon Prichard say their proposals protect vulnerable kids from a social contagion proliferated by left-wing political ideology.

A transgender activist and a psychiatrist who treats adolescents experiencing gender dysphoria say the legislation defies the medical field’s best practices and represents a grave threat to transgender youth, who are already at heightened risk for depression and suicide.

VanWinkle confirmed to Forum News Service she is sponsoring a bill that would criminalize gender-affirming care for minors.

Under the Minot lawmaker’s proposal, North Dakota doctors who perform sex reassignment surgeries or prescribe hormone treatment or puberty blockers to transgender minors would be guilty of a Class B felony, punishable by up to 10 years in prison and a $20,000 fine.


Prichard has drafted a separate bill that would create a civil penalty applying to doctors who perform gender-affirming care for minors and to parents who approve the treatments for their children. The legislation would allow people who received the surgeries or treatments as minors to sue for damages in civil court.

The 21-year-old Bismarck representative said he supports a criminal penalty for medical providers, but he worries that “activist” county prosecutors might not pursue charges against doctors for performing gender-affirming care.

VanWinkle also plans to bring legislation that would bar schools and other public entities from making special accommodations or designating specific facilities for transgender children. That proposal would effectively restrict transgender students’ access to school restrooms aligning with their gender identity. VanWinkle said the language may constitute a separate bill or a section in her original bill.

All of the legislation is still in draft form and may undergo minor changes before lawmakers begin their four-month session in January, Prichard said.

North Dakota Rep. Brandon Prichard, R-Bismarck, stands in the North Dakota Capitol.
Jeremy Turley / Forum News Service

When the bills are formally introduced, it will mark the second legislative session in a row where restrictions related to transgender youth will be on the table. North Dakota lawmakers passed a bill in 2021 to limit transgender athletes’ participation in K-12 sports, but Republican Gov. Doug Burgum vetoed the proposal.

In recent months, courts have blocked laws to ban gender-affirming care for minors in Texas, Alabama and Arkansas.

What is gender dysphoria?

Many transgender people suffer from gender dysphoria, which is defined by the American Psychiatric Association as a sense of unease resulting from an incongruence between one’s sex assigned at birth and one’s gender identity.

Medical providers like Bismarck psychiatrist Dr. Gabriela Balf may diagnose adolescents with gender dysphoria if they have experienced psychological distress for at least six months due to a mismatch between their gender identity and their assigned sex at birth.


Balf, who also serves as a part-time professor at the University of North Dakota, said children in the state identifying as transgender is not the “epidemic that some parents and some legislators have been concerned about.”

By the time North Dakota transgender adolescents reach the stage where they qualify for medical treatment, their proportion of the population is only about half the national proportion of transgender youth seeking gender-affirming care, Balf said.

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders — often regarded as one of the bibles of psychiatry — sets out criteria for diagnosing gender dysphoria, but Balf said a doctor’s task is much more complex than ticking a few boxes. Diagnoses of gender dysphoria and any accompanying comorbidities come after hours of professional evaluation, she noted.

Balf recognizes some people want evidence that gender dysphoria exists beyond medical textbooks. She cited multiple studies of brain imaging published since 2015 that reveal differences in brain anatomy between transgender and cisgender people.

A study published in the Journal of Clinical Medicine in March found evidence to support the idea that “underlying brain anatomy in transgender people is shifted away from their biological sex towards their gender identity.”

What medical treatment do transgender adolescents receive in North Dakota?

Children receive no gender-affirming medical treatments prior to puberty, Balf said. Many pre-pubescent kids experiment with gender ideas, but the majority change their mind when they hit puberty, she noted.

After puberty begins, children diagnosed with gender dysphoria may receive puberty blockers — decades-old drugs, like Lupron, used to treat a variety of medical conditions.

The injections “hit the pause button” on the development of secondary sex characteristics, like breasts in women and facial hair in men, Balf said. The effects of the drugs are reversible, and children may undergo puberty normally once off the medication, she added.


If transgender teens forgo puberty blockers until they turn 18, the development of secondary sex characteristics may cause extreme mental distress and compromise their ability to “pass” as their gender identity later in life, Balf said.

Adolescents also see a mental health specialist with training in transgender care while they are taking puberty blockers.

The main risk of the injections is loss of bone mass, but Balf said that complication is reversible.

Few transgender adolescents in North Dakota are given sex hormone treatment before their 18th birthday, Balf said. Hormone therapy — usually in the form of estrogen pills or testosterone injections — produces physical changes that would normally occur during puberty. Its effects are partially reversible, Balf said.

Gender-affirming surgery, also known as sex reassignment surgery, has never been performed on a minor in North Dakota, Balf said. Studies show that less than 1% of people who receive gender-affirming surgery regret it after the fact, she noted.

A Reuters investigation published in October found that little research has been conducted to study the long-term effects of puberty blockers and hormone therapy on transgender adolescents.

The report illustrated that debate among doctors continues over how to medically treat an increasing number of transgender youth.

Some gender-care providers have urged a more cautious approach in the prescription of puberty blockers for children, though most still recommend the treatments in at least some adolescent cases, according to a New York Times examination.


Balf believes the benefits of the treatments outweigh the risks for adolescents struggling with diagnosed gender dysphoria. The alternative to puberty blockers and hormone treatment for transgender youth is often depression, suicidal thoughts and drug abuse, the doctor said.

The World Professional Association for Transgender Health (WPATH) concluded in its most recent “Standards of Care” document that although more research is needed, an “emerging evidence base indicates a general improvement in the lives of transgender adolescents who, following careful assessment, receive medically necessary gender-affirming medical treatment.”

To ban or not to ban?

The debate about whether gender-affirming treatments should be legal in North Dakota centers on a fundamental disagreement over how to look after distressed children.

VanWinkle, a real estate agent, said her “common moral sense” proposal protects kids “because they cannot comprehend the severity of this decision at such a vulnerable age.

“(Transgender youths) are already at risk for mental health challenges, so why on earth add insult to injury by allowing them take a scalpel to mutilate their genitalia, or give place to their mental trouble and prescribe hormone therapy, when these irreversible actions will never make their disillusioned condition into any true reality?” VanWinkle said in an email.

“They will never become the other sex, no matter how much they pump their body with different hormone therapy, or mutilate and rearrange their genitalia. It is creation that made them male and female; no surgery, no pronoun, no accommodation, can redefine that,” she continued.

Prichard, a college student, said the medical field’s willingness to provide gender-affirming care to minors is grounded more in a political agenda than sound scientific evidence. The legislator claimed some parents hold a “viewpoint where they want to push it on their children.”

He added that doctors should not entertain patients’ dysphoria while treating it.


“Treating the dysphoria is about providing the psychological and sometimes psychiatric care needed to make sure that that child … gets back to the mental state where they can function normally as a normal rational human being,” Prichard said.

Balf believes VanWinkle and Prichard are probably well-intentioned, but she questions whether they should be looking to restrict medical practices applied by highly trained professionals.

Transgender adolescents are much more likely to struggle with mental health challenges and drug abuse if they cannot access gender-affirming care, Balf said.

As it is, nearly a fifth of transgender and gender nonbinary youth reported a recent suicide attempt in a national survey released this year by the Trevor Project, a nonprofit focused on suicide prevention for the LGBT community.

“From a public health perspective, it’s a bad idea to have citizens without medical knowledge or a public health background interfering with medicine,” Balf said. “Lives will be lost.”

Katrina Jo Koesterman, president of advocacy group Tristate Transgender, said the legislation proposed by VanWinkle and Prichard is “incredibly dangerous.”

“These bills attack the very center of what it is to be trans. I’ve believed for a very long time that the only cure for gender dysphoria is gender expression,” Koesterman said. “If you block gender expression, you block any sort of hope for positive mental health.”

The 36-year-old Moorhead resident, who identifies as transfeminine and nonbinary, said conservative lawmakers are promoting hateful legislation targeting the transgender community because it is politically advantageous.


Katrina Jo Koesterman is president of Tristate Transgender.
David Samson / The Forum

House Majority Leader Mike Lefor, R-Dickinson, said he has not read the bills and declined to comment on them.

House Minority Leader Josh Boschee, D-Fargo, declined to comment on specifics of the bills, but he said he trusts doctors and medical best practices.

“I find it very concerning that some of our new legislators say they want to keep the government out of people’s lives yet they’re proposing laws telling people what they can and can’t do,” Boschee added.

Jeremy Turley is a Bismarck-based reporter for Forum News Service, which provides news coverage to publications owned by Forum Communications Company.
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