As a 12-year-old girl, Phoenix Moncada was petrified and confused by the physical changes of puberty — and resorted to cutting, or self-mutilation, over and over again.
At the time, a social worker, foster parents and therapist pigeonholed the child, known then as Christina, as a troubled, pubescent girl who acted out for attention. But Moncada, now 21, says the behavior reflected more than adolescent insecurities.
“I didn’t like my body,” said Moncada, a Sacramento resident who since has transitioned to male. “It was growing in a way I didn’t want it to grow. I just wanted the pain to go away.”
Moncada’s doctor prescribed antidepressants and suggested he might have a personality disorder. Desperate to feel happy, Moncada went along with the medications, saying he “trusted the system” to watch out for his best interests.
He never knew his legal or health care rights, he said.
Legislation pending in the California Senate would require that foster children be educated about their right to seek “gender-affirming health care,” which is covered by Medi-Cal, the state’s health insurance program for low-income Californians and foster children up to age 26.
Foster kids already have the right to seek “gender-affirming” care under state law, but advocates say they often don’t realize that and have been denied care. AB 2119 would add that right to the Foster Youth Bill of Rights, a list of 27 rights that is provided to California’s roughly 60,000 foster kids when they enter the system. The list includes basic provisions such as the right to live in a safe, healthy and comfortable home.
Caring for transgender children is both an emerging and controversial field of medicine among professionals, with sparse data about how it affects health, according to the Center of Excellence for Transgender Health.
A key point of contention is what “gender-affirming health care” means for a person diagnosed with gender dysphoria, defined by the American Psychiatric Association as a conflict between a person’s physical gender and the gender with which they identify.
To supporters of the bill, which has already sailed through the state Assembly, providing “gender-affirming” care simply means access to doctors who can help foster children navigate the confusion of feeling like someone trapped in the body of the opposite sex. It can include counseling, hormone therapy and surgery, although the bill doesn’t go into detail or specify any treatment. Supporters include Equality California, the American Academy of Pediatrics, the ACLU and groups that represent behavioral health workers.
Opponents say the bill opens the door to prescribing minors so-called hormone blockers that stop puberty, or even gender-reassignment surgery that would transition children to the opposite sex — choices they say come with long-term health risks that are unnecessary since gender dysphoria often goes away on its own. Opponents include religious groups and an association of socially conservative pediatricians.
“Children have developing brains. I know this as a physician. I know this as a foster parent. Their minds change often. They don’t grasp long-term consequences,” said Dr. Andre Van Mol, who co-chairs the committee on adolescent sexuality for the American College of Pediatricians. “Children should not be pressured into making permanent decisions that alter their bodies.”
The college, which opposes the bill, believes that when gender dysphoria occurs before puberty, “it resolves in 80-95 percent of patients by late adolescence after they naturally pass through puberty.”
Supporters call those statistics outdated and biased. At a recent legislative hearing, Dr. Jennifer Hastings, a family practice doctor in San Francisco who specializes in transgender health care, told lawmakers that other studies show withholding “gender-affirming care” can in fact increase depression, anxiety and suicides among children.
“I have taken care of foster youth who really struggled to access care in their counties and this affected them negatively in their mental health and in their medical health,” Hastings said. “Truly, this care is lifesaving.”
Although California’s child welfare laws and regulations are some of the most comprehensive in the country for transgender youth, experts say many foster kids often are unaware of their rights.
“These children are unable sometimes to receive medically necessary care that they need,” said the bill’s author, Assembly member Todd Gloria (D-San Diego).
California, nine other states and the District of Columbia provide protections for foster children’s sexual orientation and gender identity, according to a 2017 report by Lambda Legal, a national nonprofit that advocates for the civil rights of lesbians, gay men, bisexuals, transgender people and those with HIV.
But California would be the first state to explicitly tell foster kids about their right to “gender-affirming health care,” said Currey Cook, an attorney at Lambda Legal. That’s important because foster kids often face bias and ignorance of the law from foster parents and case workers, he said.
“Just because you have a good law on the books doesn’t translate into every kid getting care,” Cook said.
The focus on foster care is warranted, advocates say, because transgender youth are overrepresented in the foster system. A 2014 study by the Williams Institute at UCLA found that 5.6 percent of foster children in Los Angeles County identified as transgender. That’s more than twice the percentage in the general population.
Critics of the legislation say those numbers are high because foster youth often have underlying issues that need to be addressed, such as previous abuse and family separation. Once those are resolved, they argue, doubts about gender identity often disappear.
John Jackson, president of William Jessup University, a Christian college in Rocklin, Calif., wrote in a letter opposing the bill that it would silence foster parents and other caregivers who want to educate kids about sexuality from a religious and ethical perspective.
“There will be no opportunity for those caregivers to provide help and support to individuals who are confused or who seek to change their gender orientation,” Jackson wrote.
In 2015, Democratic Gov. Jerry Brown signed legislation requiring officials to consider the gender identity of children when placing them in a foster home. Providing transgender kids an easier path to “gender-affirming care” is the next step, advocates say.
Moncada wishes he could have had that support and treatment during what he describes as the isolating and depressing years of his adolescence.
He connected with an LGBTQ group when he was about 16, and said he finally felt the freedom to explore his identity. Even then, he said, he thought the law required him to wait until he was 18 to begin hormone therapy. It was a process he wished he could have begun earlier.
“In any other situation, if you saw someone going through pain, you would try to fix it,” Moncada said. “Why can’t we do something about this?”