In many ways, Alex Lounsbury has been lucky. He knows that.

Now in his senior year at Atkins High School, a technology magnet in Winston-Salem, N.C., he’s happy, healthy and looking toward the future. But it wasn’t easy getting there.

Assigned female at birth, Alex knew he was transgender by the time he was in middle school. But he wasn’t ready to talk about it with parents, teachers and all of his friends right away. When he did come out to his family, they were supportive.

“They just wanted me to be healthy and happy,” Lounsbury told Policy Watch this week. “I know a lot of people don’t have that from their parents. I wish everyone did. They wanted me to be myself and be who I really am.”

For Lounsbury and his family, that meant transitioning. First socially: telling friends, family, teachers and administrators he was changing his name and his gender pronouns. Nobody was ready for it, he said. The school had never encountered a transgender student.

“There was bullying, even assault,” he said. “But my parents supported me. We sat down with teachers, the principal. It just took time and persistence.”

At 16, he and his family began talking with doctors about hormone replacement therapy to begin a physical transition. In a few months, he’ll take the next step — a “top surgery” to remove his breasts, which he’s been working toward slowly and deliberately for years. At every step, with the backing of his family and the knowledge and advice of his doctors, he’s felt more at home and at peace in his own body.

As he moves toward graduation this year, he’s happy the environment has changed for young trans people since he came out.

“It’s just something people understand a little better now, they know about it more,” Lounsbury said. “Teachers hand out introductory cards at the beginning of the year, asking about preferred names and pronouns. That’s really helpful. There’s more of an understanding.”

But under two new bills moving through the North Carolina General Assembly, that could all radically change.

Senate Bill 49 would, among other provisions, require teachers to notify parents if a student questions their own gender — outing many young trans people before they’re ready to tell their families, who might be hostile to their identities.

House Bill 43 would make it illegal for anyone under 18 to receive the sort of gender affirming care Lounsbury did.

Lounsbury can’t help thinking of how much more difficult his life would have been under laws such as these.

“This would have been my nightmare,” he said. “Being outed, not being able to speak my truth about who I really am in my own time, when I decided to. And to not be able to make a decision with my family and my doctors. I don’t see why it’s anybody else’s place to say, why they belong in that conversation.”

For Lounsbury and many transgender youth, the two bills offer a perplexing insight into what Republican lawmakers believe to be the place of government in family and medical decisions.

Under SB49, the so-called “Parents’ Bill of Rights,” the place of parents is paramount in any discussion of gender, sexuality and identity. Its sponsors argue the government — in this case, through teachers and school administrators — has no place in conversations about a young person’s gender identity without them.

But under HB43 parents like Lounsbury’s, who support their transgender children and follow the standard of care prescribed by doctors and myriad medical associations, would see the government intervene to prevent any steps toward transition until they are 18.

These contradictory ideas about family versus government seem to be bridged by one overarching belief, Lounsbury said: the assumption that being transgender is dangerous, something to protect children against even if their families and doctors don’t share that view.

“What they’re saying is the parents should have these conversations and make these decisions — unless they support you,” Lounsbury said. “Then the government just makes the decision it wants them to. It’s only the parents who are against it whose rights matter.”

After years of advocacy, transgender North Carolinians have finally made progress, securing hard-won legal victories?about their rights to gender-affirming health care coverage and the right to change their gender marker on government documents.

But now they are facing a backlash. More than 200 anti-LGBTQ bills have been filed across the country already this year. Republicans who picked up seats in state houses are pushing through legislation and will likely use it campaign on in the next election cycle.

The certainty of a veto from Gov. Roy Cooper, a Democrat, kept Republican leaders in the North Carolina General Assembly from even bringing some anti-LGBTQ bills to a vote in the last legislative session. But with gains in the last election, Republicans ?again have the votes to override a veto in the Senate and need the support or absence of just one Democrat in the House to override it that chamber.

That new legislative math makes bills codifying the most conservative view of gender identity a real possibility, despite the objections of LGBTQ families and the mainstream medical community.

“It doesn’t feel like a step back, it feels like a couple of hundred steps back,” Lounsbury said. “It’s completely and utterly terrifying to know that just being myself is possibly going to become illegal in some ways.”

Doing measurable damage

For State Rep. Marcia Morey (D-Durham), the attacks on LGBTQ people aren’t new. One of the General Assembly’s few out LGBTQ legislators, she’s spent years promoting bills that would offer greater protections for these marginalized communities. Under a Republican majority, those bills can’t even get a hearing.

With these new bills aimed at gender identity, Morey said, GOP lawmakers are sending a very clear message.

“The damage that we’re doing by introducing these bills is that it communicates to certain young people that something is fundamentally wrong with them,” Morey said. “They’re watching, they’re listening. They’re paying attention as we’re trying to legislate their identities at a very tender time.”

This week State Rep. Vernetta Alston (D-Durham), another out legislator, sponsored a competing House bill she said will account for the rights of both parents and students — including families like hers.

Alston and her wife are also parents, she said in a press conference Tuesday. LGBTQ students and their families need to be acknowledged when lawmakers legislate gender identity and sexuality.

“Like so many parents, my number one priority in life is the health, safety and well-being of my children,” Alston said. “Instead, my Senate colleagues are debating bills like Senate Bill 49 … a bill that will harm our students, especially our LGBTQ students who will only be more vulnerable and more isolated at school if Senate Bill 49 passes.”

A Department of Health and Human Services report ?shows a 46% increase in North Carolina youth reporting a depressive episode since the COVID-19 pandemic began nearly three years ago. One in five high school students seriously contemplated suicide last year, according to the report. For LGBTQ students, that number is one in two.

Medical experts point to years of studies that show legislation targeting LGBTQ youth, particularly in schools where many find support they lack at home, contributes to a rise in depression and suicidal ideation. On Wednesday a panel of doctors from Duke University who study the issue and treat LGBTQ young people spoke out against the bills now moving through the legislature.

“There is a high likelihood both these bills … would have reverberating impacts on the health of LGBTQ+ children and adults throughout North Carolina,” Dr. Sarah Wilson, assistant professor in the Department of Psychiatry and Behavioral Sciences and co-lead of the Duke Sexual and Gender Minority Health Program.

That’s clear when studying the aftermath of HB2, Wilson said. The 2016 law excluded lesbian, gay, bisexual and transgender people from statewide nondiscrimination protections. That legislation caused a national firestorm, with protests and boycotts leading to a partial repeal.

For LGBTQ people who lived through having their identities and rights debated and assailed daily throughout that controversy, the effects were devastating. Wilson pointed to a two-year study in HB2’s wake, highlighting a number of alarming trends.

“In North Carolina after HB2 … we saw gender identity-motivated hate crimes actually increased in the state,” Wilson said. “So there can be these larger cultural effects of the legislation that can adversely affect LBTBQ+ individuals by normalizing stigma. Where there is stigma, oftentimes there is increased violence.”

During the HB2 controversy and its aftermath, state lawmakers promoted right-wing groups that opposed same-sex marriage while rejecting the medical mainstream conclusions of the American Medical Association, American Psychiatric Association and American Academy of Pediatrics. That came at a cost, Wilson said.

“There are downstream effects of that increased exposure to stigma, violence and hate crimes where North Carolinians who are LGBTQ+ reported feeling increased depression and anxiety,” Wilson said. “This is a group that already faces disproportionate rates of discrimination, harassment, stigma, and these bills serve to potentially have an amplifying effect for these inequities we already see.”

Transgender people — especially youth and people of color — suffered the greatest negative impact.

“Suicidal ideation increased among transgender and gender non-conforming North Carolinians, and hate crimes increased,” Wilson said. “Depression and anxiety among transgender North Carolinians also increased. We saw these reverberating effects throughout people’s lives. We saw people delaying health care because of these bills because there was a concern over general attitudes towards transgender and non-binary folks.”

Limiting what students can hear, read and say about gender identity in their schools is particularly dangerous, Wilson said, as LGBTQ youth often find badly needed support and community there.

“We know the majority of LGBTQ+ youth report their home is not LGBTQ+ affirming — three in five,” Wilson said. “The rates are actually a little bit higher for schools. There are more LGBTQ+ who report their school is an affirming place than report their home is an affirming place.”

“Youth and adults turn to friends, teachers, other people in the community to be able to gain that acceptance and willingness to support the person regardless of their sexual orientation or gender identity,” Wilson said.

Sponsors of these bills see that as the problem.?“Parents do not surrender their children to government schools for indoctrination opposed to the family’s values,” said Sen. Amy Galey, an Alamance County Republican and one of SB49’s main sponsors, said during a press conference last week.

That view was amplified in a Senate Rules committee meeting this week, where members of the conservative group Moms for Liberty made clear the religious motivations of the bill’s supporters.

“It seems that it would be extreme emotional abuse by the system to allow a child to believe and grow into something that is against the definition given by the Bible of truth and God’s word as far as their sexuality,” said Nicholas Jaroszynski, a board member of Moms for Liberty of Iredell County.

“To allow the state to define that is even further of an abomination,” Jaroszynski said.

The view that acceptance and support for LGBTQ students amounts to indoctrination is problematic and scientifically unfounded, said Dr. Dane Whicker, a clinical health psychologist at Duke Health who provides therapy for LGBTQ+ adolescents and adults.

Decades of scientific research doesn’t support the political narrative that young people become LGBTQ because of outside influence, Whicker said, while volumes of research demonstrate that trying to prevent LGBTQ people from embracing their identities is harmful.

“There are no interventions or practices that can stop youth from having LGBTQ+ identities,” Whicker said. “In reality these types of bills, the impact they’re going to have, is on concealment – people hiding really important parts of their identity and depriving them of the support they need to navigate those really critical pieces that affect their health and trajectory in life.”

“New territory for a lot of people”

Dr. Deanna Adkins, a pediatric endocrinologist at Duke Health and director of the Child and Adolescent Gender Care Clinic, has spent years working with hundreds of transgender patients.

The debate around gender affirming care has unfortunately strayed far from the realities of how doctors like her actually work with families and young transgender people, she said this week.

“Gender-affirming care is life saving care with decades of research behind it,” Adkins said. “You wouldn’t ask me to not practice the standard of care for any other care I give. You wouldn’t ask me to not do what the American Diabetes Association says I should do for my patients with diabetes.”

Current discussions don’t reflect the reality of the care, nor the risks of suddenly making it out of reach, Adkins said.

“This is a group of individuals, a small portion of the population, only about 3% of those under 18,” Adkins said. “And they are a quite vulnerable population. It would limit their access to potentially life-saving treatments that we have excellent evidence within the medical literature that this helps these patients in many ways. It decreases their suicidality, it improves their overall mental health, it decreases self-harm as well.”

For Sage, a 13-year old non-binary person from Greensboro, gender-affirming care of the type Adkins describes has been life saving — as has been the support of their family.

Because Sage and their family have experienced harassment and threats during Sage’s transition, Policy Watch has agreed to identify them by their first name.

After consultation with doctors, Sage and their family chose to use puberty blockers for about two years to delay its onset. The extra time allowed Sage to more consciously work through their gender identity and the steps they wanted to take to prevent gender dysphoria — the distress that comes from a misalignment of one’s body and gender identity.

The process was simple, safe and reversible, Sage and their family said.?“I had a lot of questions, of course,” said Sage’s mother, Debra. “This is new territory for a lot of people, us included at that time. We talked a lot with the doctors about what could be done, possible side effects, steps for the future. Ultimately, we weighed this treatment against the dangers of our child not wanting to live in their body and we made the decision that would make them healthy and happy. And they are.”

Legislation could soon prevent other young transgender people from having the same experience. That’s something Sage, still on their journey of transition, thinks about a lot. They’ve stopped puberty blockers and are weighing next steps, such as hormone therapy or eventually, surgery.

But having those options taken off the table by people outside the circle of their family and their doctors feels wrong.?“It’s really scary to me that the things that have been available to me might not be, and that could happen in a matter of weeks,” Sage said.

Adkins said she is hearing that concern from patients and their families daily. Without access to safe gender-affirming care, she said, there’s a danger some will turn to black market medications and treatments that aren’t safe and tested, out of desperation.

That’s not something their family will do, Sage’s mother Debra said. But they will take their child out of state for treatment if needed, she said, or even consider moving if it becomes necessary.

“This isn’t something that the government should be involved in, when a person and their family and their doctor make the decisions that are best for them,” Sage said. “Having freedom in this country, including freedom of religion, also means having freedom from having someone else’s religion used against you.”

Sage’s mother, Debra, said she’s proud her child felt supported enough to speak openly with her and her husband about their gender identity — and proud that their family has navigated this journey with love.

That’s not the story every LGBTQ person has, she said. Some face physical violence or abandonment by their families. Others face so-called “conversion therapy” — a scientifically debunked and harmful practice North Carolina has yet to ban.

“We need to be doing everything we can to make this easier for our kids, not harder,” Debra said. “For every kid who isn’t lucky enough to have the full support of their family, who doesn’t have access to the care they should, we shouldn’t be making this harder.