“This is just between us, right?” one of my students asked, her voice trailing off as she adjusted her navy blue backpack and got up to leave.

I reassured her that this was a confidential, safe space to share any feelings, experiences, or questions that she may have. “Ok” she replied, looking relieved, her shoulders relaxing, “see you next week.”

As a mental health clinician practicing in a large school setting, students talk to me about many issues, including their gender identity, gender dysphoria (defined by the American Psychiatric Association as a conflict between a person’s physical or assigned gender and the gender with which he/she/they identify), and sexual orientation. And they talk to me because they trust that I will keep what they share confidential.

There are certain legal exceptions to student/provider confidentiality. If school clinicians suspect a student is being abused or neglected, or if a student expresses suicidal ideation, we must follow a clear intervention plan to protect the student.

However, with the overwhelming majority of issues and experiences that students come to talk about, it is the privacy of the space that prompts them to come and seek support in the first place. It is the understanding that they can speak freely and those words do not go beyond the walls of this office.

But if Republicans in many states get their way, this guarantee of confidentiality will be destroyed.

Ohio Republican Representatives Tom Brinkman and Paul Zeltwanger recently introduced legislation, House Bill 658, which, if passed, would require school therapists and teachers to “out” transgender students to their parents.

HB 658 states, “If a government agent or entity has knowledge that a child under its care or supervision has exhibited symptoms of gender dysphoria or otherwise demonstrates a desire to be treated in a manner opposite of the child’s biological sex, the government agent or entity with knowledge of that circumstance shall immediately notify, in writing, each of the child’s parents and the child’s guardian or custodian.” 

The law would also punish therapists with felony charges if they do not comply with outing children.

HB 658 perpetuates the dangerous belief that if we forbid children from receiving therapy, if we scare them with the threat of being outed by a trusted therapist and we impede their ability to gain any validation and gender-affirming support, then their gender identification isn’t real. Then all of this will just go away.

Republicans claim the reason for this proposed bill is a supposed concern for “parents rights.” The belief is that parents should have to consent to any form of treatment, including just speaking to a school therapist, regarding a child’s gender identity or gender dysphoria. 

Yet despite the pretext for this law, the fact remains that parents rights are not being impeded; their rights are still overwhelmingly protected by state law.

State law already requires that parents give consent for a transgender child to begin hormone blockers, take testosterone or estrogen, or have gender reassignment surgery. But now Ohio is trying to infringe on whether or not a student can even talk to a school therapist or teacher about their gender identity, effectively turning school providers into gender informants.

And Ohio isn’t the only state trying to violate transgender student rights. There has been a startling increase in legislation targeting transgender children. In the last three years 44 anti-transgender pieces of legislation have been introduced in various states, with 23 of those targeting transgender children in schools and in playing school sports. 

Ohio is trying to infringe on whether or not a student can even talk to a school therapist or teacher about their gender identity, effectively turning school providers into gender informants.
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These types of legislation are particularly dangerous given that transgender students are already at an increased risk for anxiety, depression, suicidal ideation, and becoming homeless due to parents kicking them out (after discovering their gender identity). 

A study published in the Journal of Adolescent Health, led by Sari Reisner and Mathew Mimiaga, research scientists at the Fenway Institute and Harvard University, found that transgender youth are at a higher risk for depression, anxiety, suicidal thoughts, and self harm than non-transgender adolescents, and that the need for gender-affirming mental health treatment and other support services is essential to their well-being. 

Currently, of the 1.6 million adolescents and young adults who are homeless in America,  40% of them identify as LGBTQ, according to research done at the Williams Institute at UCLA Law. 

In addition, 46% of homeless LGBTQ youth left the home because of their family’s refusal to accept their sexual orientation or gender identity; 43% were kicked out by parents, and 32% reported enduring sexual, emotional, or physical abuse in their family home. 

How many more will be abused or become homeless after they are forcibly outed by their schools?

Jenn Burleton, executive director of the TransActive Gender Center, reports that “Many transgender kids living with unsupportive parents may be able to hold on, emotionally, because of support through school counselors or Gay-Straight Alliances. But in one fell swoop, this bill would eliminate any support system at their schools…their goal is Draconian.”

How many more will be abused or become homeless after they are forcibly outed by their schools?
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In many ways HB 658 creates a state-sanctioned witch hunt. Where does it end? The proposed law says that any student who “exhibited symptoms of gender dysphoria or otherwise demonstrates a desire to be treated in a manner opposite of the child’s biological sex” must be reported to their parents. 

Are schools now supposed to be spies for any possible non-conforming gender expression? 

“Who is the judge of which gender is allowed to do what? If Jane signs up for shop class, will her parents receive a government letter? If Jordan doesn’t want to play football, do his parents get a letter? What if Alex wants to attend a meeting of the student LGBTQ group–does the school email that to Alex’s parents? Just what stereotypes are they expected to enforce?” states Ohio’s Equality Now in response to this bill.

In addition, forcing clinicians to report non-conforming gender expression or gender dysphoria to parents, even though many of them may react violently, would only cause students further harm and violates our duty to protect children.  

Therapists cannot ethically report a child’s gender expression or dysphoria if it is told to us in confidence, and even more so if we know that child will then be at an increased risk for abuse or being thrown out of their house. 

The repercussions of the proposed Ohio law (and many other pieces of anti-transgender legislation in other states) would be catastrophic for all transgender students—and those who are the most vulnerable will no longer seek out support if they now have to fear being “outed,” which then elevates their risk for depression and self-harm. 

The National Association Of Social Workers (NASW) has condemned HB 658 stating, “We are outraged by the legislation that is so clearly in violation of everything the profession of social work stands for.” The American Counseling Association (ACA) also weighed in on HB 658, stating the bill “negates client rights to confidentiality and attacks the very basis of a key mandate for counselors: to provide counseling to those who need it and have nowhere else to turn.” The risk to students is especially pertinent in Ohio, where abuse of transgender students has already been well documented. 

A recent study found that 64%of LGBTQ youth in Ohio have heard disparaging comments about being LGBTQ from family members and only 23% of LGBTQ youth in Ohio have come out to close family members about their sexual orientation. The study also found that 12% of LGBTQ youth in Ohio were sexually assaulted/raped due to their presumed or actual LGBTQ identity, 69%of LGBTQ youth in Ohio are harassed in school, and an alarming 70% of LGBTQ youth in Ohio have received unwanted sexual commentary and inappropriate and lewd jokes in the past year.

While the legal challenges to this law, if it passes, are inevitable, this type of anti-transgender legislation that is exploding around the country, plays into the larger cultural battle of denying transgender students their basic right to exist, to seek support, and to have their own autonomy.

Students will no longer have the ability to come out when they are ready, they will be forced out. And even those who have more support and aren’t at risk for abuse at home will still be forced to come out on someone else’s terms.

Corey Vickman, a 15-year-old transgender student in New York City, shared that “While I have a supportive family and school, coming out can still be terrifying for many transgender students. I can only imagine how devastating it would be to have that option taken away from you, especially by someone you have confided in.”

Even those who have more support and aren’t at risk for abuse at home, will still be forced to come out on someone else’s terms.
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You can’t scare a child into not being transgender or non-binary. No amount of threats, rules, or regulations will keep someone from experiencing dysphoria. School clinicians are there to support students, and requiring them to “out” children, to put students at an increased risk for harm and to betray their trust, violates the core principles of what we do.

And we will do everything we can to stop this dangerous legislation. 

**Names have been changed to protect the identity of minor children**

“Your baby has no heartbeat.”

I stared at the doctor in shock, my eyes instantly stinging with tears as his words sunk in.

I looked back and forth from the devastated look on my husband’s face to the sonogram screen, silently pleading for that tiny little black and white flicker to suddenly appear, unable to believe this was really happening.

How could the baby, who was developing so well for the last nine weeks, just be gone?

Within moments of hearing those devastating words, I was told I would have to have a D&C, that this was my only treatment option.

Ten to twenty-five percent of all pregnancies end in miscarriage. In some cases a woman may wait and see if the body naturally expels the tissue, but this is not a viable or recommended option for many people. This is when a dilation and curettage (D&C) may be needed. A D&C is a surgical procedure, typically done in the first trimester, to remove tissue from inside your uterus after a miscarriage. The patient is placed under general anesthesia — or, in very rare cases, under heavy sedation — while the procedure is done. (There is also a D&E procedure that removes tissue and also requires anesthesia, but this is typically used after the first trimester.)

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Historically, the D&C has been the dominant treatment method for people after a miscarriage, and it has generally been considered safe — and for some, it may be necessary. But there is an increased risk of complications whenever anesthesia is used, due to potential reactions to the medication and resulting breathing problems. And for those who already have a history of reacting unfavorably to anesthesia, this can add additional complications.

Recent studies have also found that there may be more risks to a D&C than previously thought. Researchers from the European Society of Human Reproduction and Embryology analyzed 21 different studies on D&Cs and discovered that the procedure is connected with a 29% greater chance of preterm birth (defined as birth occurring before 37 weeks) and a 69% greater chance of very preterm birth (less than 32 weeks) in a future pregnancy. This study of almost 2 million women also found the risk of prematurity was even higher in women with several previous D&Cs.

This is not intended to cause alarm in women who have already had a D&C, or to endorse one procedure over another — but patients should always be advised of every option available to them, not just the standard D&C.

Manual vacuum aspiration (MVA), for instance, is a safe treatment option in an early miscarriage. In this procedure the cervix is numbed and tissue is removed with a hand-held device (MVA) or a small electric device (referred to as an EVA). The procedure lasts, at most, 10 minutes. The patient remains completely awake and alert the whole time, and it is now the recommended method of treatment for early miscarriages by the World Health Organization. The Journal of American Science also reports that the MVA is effective, less time consuming, and less costly, and since it doesn’t require general anesthesia, the risk of complications is less than a D&C.

Patients should always be advised of every option available to them, not just the standard D&C.
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Another study published in The International Journal of Obstetric and Gynecology reports that the MVA is “an alternative to the standard surgical curettage, performed under local anesthetic. It is a safe, and possibly cost-effective procedure, with advantages for both the patient and the health-care system.”

There is also a medication option where a patient is given misoprostol, a drug that causes the tissue to pass. Patients take the pills at home and often have to follow up with their doctor afterwards to ensure the procedure was effective.

I was not informed of these other options after my own miscarriage by any provider, including my doctor, a highly-regarded physician in New York City, and the staff at the surgical center. As a clinician that has worked in a medical setting, and with patients who have miscarried, I was already aware that other options to the D&C existed, but none of my providers discussed these with me. At one point I was even told by staff at the center that “if you have a miscarriage then you have to get a D&C.”

When I met with the “counselor,” employed by the surgical center to speak with patients before they see the doctor to inform them of treatment options and review consent forms, they only brought the information and consent forms for the D&C and said nothing about the MVA or the option to take misoprostol at home.

I continued to refuse the D&C. Having had difficulty with anesthesia in the past, I saw no need to have this if it wasn’t absolutely necessary, and finally, after going through multiple staff members and supervisors, I was given the proper consent forms for an MVA and was taken to one of the on-duty doctors who confirmed that an MVA is an applicable treatment option in an early miscarriage.

In speaking with many other women who have also been in this situation, they too shared stories of not being informed that there were other options, and many told me they had never been told that the MVA procedure even existed.

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There are compelling reasons why patients might not be getting a full picture of their options after a miscarriage, the location of where the procedure is performed being one. Many D&Cs continue to be performed in hospital operating rooms, despite the advances in miscarriage management, and even though, with the exception of certain complicated cases, there is no longer a medical need that necessitates a patient going to the hospital after a miscarriage for a D&C.

This is often due to physician preference rather than what the patient wants. Studies have shown that medical providers’ attitudes toward newer treatment have remained stagnant, that many physicians still utilize the older D&C method and still prefer to treat pregnancy loss in the hospital operating room, according to research published by the Guttmacher Institute and the National Institutes of Health.

Even if a D&C is the right treatment option for a woman, it isn’t medically necessary for this to be done in the hospital and it can be performed in other medical settings, such as a surgical center or a private doctors office. Requiring people to go to the hospital OR (operating room) often adds significant stress, time, and cost to an already painful situation.

New York City-based physicians, Drs. Priypa Praditpa and Anne R. Davis, concluded in at 2015 study, “Manual vacuum aspiration: A safe and effective treatment for early miscarriage,” that the MVA is not only a safe procedure, but that “for too long, patients have blamed themselves for a miscarriage and physicians have relied on the D&C in the OR. Changes in the culture surrounding miscarriage are long overdue.”

At one point I was even told by staff at the center that ‘if you have a miscarriage then you have to get a D&C.’
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The financial aspect to the D&C likely plays a role and provides an incentive to which procedure doctors perform and where they perform it. Providers can bill insurance companies at a higher rate once anesthesia is administered and even more so if it is done in a hospital. Anesthesiologists typically bill at a base rate and then at each 15-minute interval while the patient is under their care.

Both the MVA and the medication option are considerably less expensive than a D&C, with the average cost of an MVA being less than half the cost of a D&C in the OR — $968 for the MVA, compared to $1,965 for the D&C, according to Praditpa and Davis’s research. The Healthcare Bluebook also lists the “fair” billable price for a provider to charge for a D&C as $2,728, though that can go all the way up to $6,820.

For uninsured women, the cost of a D&C can be staggering; though prices vary depending on provider and location, they often range from $4,000 to $9,000. Insured women have also reported exorbitant out-of-pocket expenses after a D&C, ranging from several hundred dollars to well over a thousand depending on their individual insurance plans. This further skews the incentive for medical providers to offer more economical treatment options.

But it’s not just about money or location. A miscarriage is already an emotional and painful time and it is every woman’s right to know all of their treatment options so they, not the medical staff or office billing manager, can make the best decision for their body — a decision based not on increasing profit or perpetuating unnecessary medical procedures, but on their individual needs.