When 13-year-old Liz Bostock thinks back, she remembers feeling in-between genders as early as preschool.
Assigned male at birth, she identified as nonbinary by fifth grade and decided to use they/them pronouns. Now a seventh-grader in Gainesville, Fla., with a passion for manga and anime video games, and a bedroom filled with stuffed animals, Liz identifies as female and transgender.
"I figured out that I actually felt like a girl," she says. "Not just in-between."
Liz's birth certificate now bears her new legal name and gender marker.
After months of counseling, and with a diagnosis of gender dysphoria, Liz started receiving puberty blockers last August. Every three months, she gets a shot of Lupron, a gonadotropin-releasing hormone, or GnRH, that essentially presses the "pause" button on male puberty.
The goal is to keep her body from developing further in ways that don't align with her gender identity.
"It's been amazing," says her mother, Virginia Hamner, who says she's seen her daughter "light up" with gender-affirming care. "It's fun and exciting for her to be able to be exactly who she wants to be," she says.
But under new rules passed by Florida's medical boards, it's unclear whether Liz will be able to continue on to further treatment.
The future is uncertain for trans kids' medical care
Florida is one of a growing number of states to prohibit gender-affirming care for transgender minors. It is the only state to do so not through legislative action, but through a vote of its medical boards.
With the encouragement of Florida Gov. Ron DeSantis, the state's Board of Medicine and Board of Osteopathic Medicine both passed rules that will ban gender-affirming care such as puberty blockers and cross-sex hormones, as well as surgical procedures, for new patients under age 18.
As for existing patients such as Liz, who may want to proceed on to cross-sex hormones (estrogen in her case; testosterone for transgender males), the language of the new rules is vague.
"There is a lot of uncertainty about that," says Hamner, who worries that the rules might be tightened still further.
"It doesn't feel like it's over, which makes living in Florida really challenging right now," she says, "because you're basically being told that your child shouldn't be able to be who they are, and that it would be better if they didn't exist in the way that you, medical professionals, and the child who is thriving, feel is best for the child."
For Liz, the fear of what's to come could mean a future outside Florida.
"If it gets too bad, I'm also already thinking about for high school going to a boarding school that isn't in Florida," she says, "which would honestly make things a lot easier."
Gov. DeSantis has targeted LGBTQ rights, and has made "parental rights," especially in education, a running theme as he eyes a potential White House bid.
The irony, says Hamner, is that her parental rights are being trampled.
"It's a gut punch," she says. "It's so frustrating to hear the rhetoric of parental rights be used to say, 'Kids shouldn't have access to treatment because we need to let them be kids.' When it's like, you're right. And guess what? That's all I want for my kid."
Politicians disagree with the medical consensus on the safety of gender affirming care for minors
Dozens of leading U.S. medical groups, including the American Academy of Pediatrics, the American Medical Association and the Endocrine Society, endorse gender-affirming care as time-tested, effective, medically necessary, and potentially life-saving.
But Gov. DeSantis has called the treatment "an example of woke ideology infecting medical practice." The state's surgeon general, Dr. Joseph Ladapo, who was appointed by DeSantis, called the treatments "highly experimental," "risky and unproven." Board of Medicine member Dr. Hector Vila said that by banning gender-affirming care, the board was acting to protect children from "irreversible harm."
The Tampa Bay Times has reported that many of the members of the Board of Medicine who were appointed by Gov. DeSantis have contributed to his campaigns or political committee.
Pediatric endocrinologist Dr. Kristin Dayton, who runs the Youth Gender Program at the University of Florida in Gainesville, disputes claims that gender-affirming care is risky or experimental.
"There is tons of evidence to back my assertion that this is safe and healthy for children," she says. "It's pretty offensive to me, because I pride myself in being someone who always follows the evidence, does the right thing for my patients."
Dayton worries about her patients, many of whom haven't yet started on puberty blockers or hormones, and now won't be able to. "People are feeling incredibly panicked and sad and distressed and coming to our office saying, 'What are we going to do when this passes?' And frankly, we don't have the answers."
Dayton's colleague, clinical psychologist Jennifer Evans, says she is "extremely concerned" about what the ban will mean for her patients' mental health. She cites research showing that medical transition has clear benefits. "Depression rates go down. Along with that, suicidal ideation and attempts go down," she says. "Anxiety goes down. Eating disorders rates start to go down. Substance abuse rates start to go down."
Doctors say medical care is being politicized and creating a climate of fear
The new rules haven't taken effect yet, but providers and advocates say they've already had a chilling impact. Several gender clinics in Florida have shut down.
Under the new rule, violators could lose their medical license and face steep fines.
Here's what a Tallahassee mom named Sandi heard from her transgender son's doctor, who explained that he will not prescribe anything beyond the son's current puberty blockers. "One thing he has said several times is 'I don't want to go to jail,'" she recounts.
As another family told NPR, the doctor said, "I don't look good in orange."
To be clear, jail time is not a penalty under Florida's new rules. But many fear that sanctions could be toughened.
That fear is shared by some families, which is why NPR agreed to use only Sandi's first name.
"We would love to be shouting at the top of our lungs all the time about all of these issues," she says. "But there's just fear of not knowing what's coming in the future and how transgender families will be retaliated against." Just look at Texas, she says, where the state investigated parents of trans kids for child abuse.
When NPR visited her at home, she was wearing a tee-shirt that says "Believe Trans Kids." "I probably have a shirt for every day of the week!" she says with a laugh. "It's a great conversation-starter."
Parents of trans children worry about "constant invalidation"
Sandi's son River (we're using his middle name, as he's not out yet to all of their extended family) started saying he was a boy, and presenting as a boy, when he was about 3 years old.
"It was like a light switch went off," Sandi recalls.
River is now 12, a 7th-grader who loves rock-climbing, math and fishing, and is a whiz with a Rubik's puzzle.
Sandi says she's seen her son flourish in the past year since he started on puberty blockers. "I have this glorious picture right after he got his first puberty blocker shot where he is literally, like, ear to ear smiling," she says. "He's glowing. I felt like he could finally put his shoulders down, like, relax."
In the current climate, she worries about what she calls "the constant invalidation" of who River is. "Constantly seeing that who you are is a political debate, [or] an agenda item on anyone's list," she says, "makes you feel less than human."
Sandi says River "has always been this solid force within himself. And so the visualization I have is, whenever there's more of this anti-trans rhetoric, it's just chipping away at that solid block of who he is."
The relentless focus on trans kids is demoralizing for her, as well. "There are some days that you look at everything going on and you are just paralyzed by fear of what's coming at your kid next," she says. "But you can't show that to your beautiful, wonderful trans kid. And it's exhausting. You know, it's so exhausting."
Sandi is on regular calls with other families who have trans kids, many of whom are planning what she calls "escape routes." They're considering moving out of Florida to more trans-friendly states.
She and her husband think about it, too; they think about moving to Oregon, where they have family. But it's hard to imagine uprooting their entire support system.
"The fact that you have to consider re-homing your family to have access to health care in the United States in 2023 is ridiculous," she says. "I just want my kid to be happy and healthy. And I just don't think that's a lot to ask."
Transgender advocates vow to fight the new rules in court
Nikole Parker, director of transgender equality for the LGBTQ civil rights group Equality Florida, has talked with a number of families who are actively planning to leave the state.
"They're like, 'Listen. The health care for my kid is my number one priority. And there are states who will allow that to happen seamlessly. And I'm not going to sit here and just wait in limbo to see what happens.' "
"As a born and raised Floridian," Parker says, "I truly feel Florida is a place for everybody, and we need to make sure that we stand firm in that. And it just makes me sad to see where we are, because this isn't the Florida that I was born in."
Trans advocates have vowed to fight Florida's new rules in court. Simone Chriss, director of the transgender rights initiative with the nonprofit public interest law firm Southern Legal Counsel in Gainesville, is among the lawyers who will lead that fight.
She's keeping a close eye on states that want to ban gender-affirming care not just for minors, but for adults, too. "I don't think that this is gonna slow down," she says. "I think that more and more states are going to ban, likely first for minors and then, you know, try to move on to adults. Which is why I think it's so critical that we stop them here in Florida."
It can feel "overwhelming and soul-crushing," Chriss admits, when she considers the cascade of states that want to ban gender-affirming care.
"It's hard not to feel like we're losing on a daily basis, which can be very demoralizing. It really does take a toll," she says. "All we can do is keep fighting."
Edited by Jason DeRose and Maquita Peters; photos edited by Virginia Lozano
