Many years ago, I saw a very good post on Reddit. Some heavily politicized bill (the ACA, I think?) was being debated, a lot of people were saying a lot of things, and this person painstakingly went through the extremely long bill and explained in plain English what it actually said. This is good! Politicians are notoriously prone to applying various spins to things to the point that the general public starts debating things based mostly on misunderstandings.
So in this post, I go through the new proposed rules for trans healthcare in Ohio, as released 5 January 2024, doing exactly that. This document is significantly shorter than the ACA was, and is easily readable by a normal human in a single sitting.
Bias notes: I am a trans woman living in Ohio, using an out of state provider for my healthcare. This means I have an interest in trans healthcare being easily accessible. This is, however, intended as a factual informative article and not an opinion article. I am not a lawyer, merely a citizen who wishes political discussion had less misinformation; I welcome corrections (ideally with citations) if anything is factually incorrect.
As of the time of writing, the Ohio government is accepting comments on these rules. Details here.
This section is essentially here so people don't argue about the definitions of words, either now or as precise meanings change over time. Definitions here only apply to this law. Other laws that may mention these terms are not affected. The authors use "sex" to mean "sex assigned at birth", immutably, and consider gender to be a separate thing. GRS is surgery that changes the way someone's body looks, for gender-related reasons. This includes both top surgery and bottom surgery. If they mean only bottom surgery, they'll say that (see (6) below). This is just gender dysphoria, with a different label. Transitioning is when one changes one's gender away from their assigned sex at birth. Detransitioning is a separate thing. Gender transition services are services for transitioning between genders. Many of the following surgeries can also be used for non-transgender-related reasons. They are only considered to be GRS if they're done for transition-related reasons. Basically anything a surgeon can do to sex organs counts, if it's for gender-related reasons. These rules apply to all trans-related medical services except surgeries.
The doctor has to consult with a psychiatrist. Same, but with an endocrinologist. The doctor has to write up what they're going to do, and have an ethicist say that it looks okay. The ethicist doesn't have to talk to the patient. It's not clear whether the psychiatrist and endocrinologist have to do anything, other than just approve the doctor's plans. I expect that, in practice, at the sort of progressive practices trans people like to use for their healthcare, this will look like these two people being around to rubber-stamp things ("yep, that looks like a normal care plan, carry on") but never actually talking to the patient. Informed consent is required. Parental consent is required for minors (the age of majority in Ohio is 18). The patient must be made aware of which things are irreversible (infertility is the one people usually get upset about). The doctor must have a plan for detransitioning. The patient doesn't have to ever see this if they don't detransition. People under 21 must go through six months of counseling before a doctor is allowed to treat them. Surgeons can't do any sort of GRS on people under 18. Doctors can't tell people under 18 where to go to get GRS, even informally. It's okay to ignore section D and do things for minors if they are some form of intersex. It's also okay if they're cis but their hormones are weird for a cis person. It's also okay if they were transitioning, and someone messed up and you're just fixing that. Providers have to submit patients' care plans to the Ohio DMHAS. It is unclear to me if this data is anonymized. I have no idea what this is about, because there is no rule 3701-3-17. 3701-3 as a whole is about communicable diseases, which doesn't seem to apply here; if I really stretch I can see them meaning 3701-3-12 ("AIDS, ARC, and HIV test reporting") via some ridiculous string of word associations (HIV/AIDS -> gay men, stereotypically -> LGBT -> trans people), but I have trouble believing that since that's already a thing they're required to do regardless of transness. 3701-17-03 is about licensing for nursing homes, which seems even less relevant.
Doctors can ignore section B if they started treating someone before they were 21. Again with that rule that doesn't exist. I assume they mean from the other document. TL;DR: no starting your transition in an inpatient psychiatric hospital. This sounds bad, but the context here is limited to inpatient psychiatric hospitals, as in the places one goes when having an extreme mental health crisis. It doesn't ban transitioning generally, even though it sounds like it does out of context. I'm very skeptical that (c), in particular, is a thing that ever happened in inpatient psychiatric hospitals in the first place. The other two do, however, sound like legitimate treatments for some cases.5122-26-19: Gender Transition Care
Section A: Definitions
(A) As used in this rule:
(1) "Biological sex," "birth sex," and "sex" mean the biological indication of male and female, including sex chromosomes, naturally occurring sex hormones, gonads, and nonambiguous internal and external genitalia present at birth, without regard to an individual's psychological, chosen, or subjective experience of gender.
(2) "Gender reassignment surgery" means any surgery performed for the purpose of assisting an individual with gender transition that seeks to surgically alter or remove healthy physical or anatomical characteristics or features that are typical for the individual's biological sex, in order to instill or create physiological or anatomical characteristics that resemble a sex different from the individual's birth sex, including genital or non-genital gender reassignment surgery.
(3) "Gender-related condition" means any condition where an individual feels an incongruence between the individual's gender identity and biological sex. "Gender-related condition" includes gender dysphoria.
(4) "Gender transition" means the process in which an individual goes from identifying with and living as a gender that corresponds to his or her biological sex to identifying with and living as a gender different from his or her biological sex, including social, legal, or physical changes.
(5) "Gender transition services" means any medical or surgical service (including physician services, inpatient and out patient hospital services, or prescription drugs or hormones) provided for the purpose of assisting an individual with gender transition that seeks to alter or remove physical or anatomical characteristics or features that are typical for the individual's biological sex, or to instill or create physiological or anatomical characteristics that resemble a sex different from the individual's birth sex, including medical services that provide puberty blocking drugs, cross-sex hormones, or other mechanisms to promote the development of feminizing or masculinizing features in the opposite sex, or genital or non-genital gender reassignment surgery
(6) "Genital gender reassignment surgery" means surgery performed for the purpose of assisting an individual with gender transition and includes both of the following:
(a) Surgeries that sterilize, such as a castration, vasectomy, hysterectomy, oophorectomy, orchiectomy, and penectomy;
(b) Surgeries that artificially construct tissue with the appearance of genitalia that differs from the individual's biological sex, such as metoidiplasty, phalloplasty, and vaginoplasty.
Section B: Requirements for treating gender dysphoria
(B) A provider may diagnose and treat a gender-related condition or provide gender transition services, other than surgical services, only after meeting all of the following standards:
(1) The provider employs or has a contractual relationship for the provision of care associated with gender-related conditions and the provision of gender transition services, other than surgical services, with a board-certified psychiatrist who has experience treating patients in the applicable age group.
(2) The provider employs or has a contractual relationship for the provision of care associated with gender-related conditions and the provision of gender transition services, other than surgical services, with a board-certified endocrinologist who has experience with treating patients in the applicable age group.
(3) The provider has a written, comprehensive, multi-disciplinary care plan that includes the following components and such plan has been reviewed by a medical ethicist:
(a) The specific services to be provided by the professionals specified in paragraphs (B)(1) and (B)(2) of this rule and other professionals from appropriate disciplines.
(b) Acquisition of informed consent from the patient and, if the patient is a minor, the patient's parent or legal guardian. Such informed consent is to include specific information about the treatments that can and cannot be fully or partially undone or reversed.
(c) A detailed plan of action for patients seeking to detransition.
Section C: Required counseling for people under 21
(C) In addition to the standards in paragraph (B), with respect to any patient under twenty-one years of age, it is impermissible for a provider to diagnose and treat a gender-related condition or provide gender transition services as described in paragraph (B) of this rule for that patient unless that patient first receives a comprehensive mental health evaluation and counseling over a period of not less than six months, documentation of which is obligated to be included in the patient's medical record.
Section D: No surgeries for minors
(D) It is impermissible for a provider to provide gender reassignment surgery or genital gender reassignment surgery or any direct or indirect referral for such procedures to any minor.
"Direct or indirect referral" includes, but is not limited to, facilitating such care in any way at another facility or providing any resources or information on where or how to receive such care.
Section E: ... unless they're intersex minors
(E) This rule does not preclude a physician from treating, including by performing surgery on or prescribing drugs or hormones for, a minor who meets any of the following conditions:
(1) Was born with a medically verifiable disorder of sex development, including an individual with external biological sex characteristics that are irresolvably ambiguous, such an as individual born with forty-six XX chromosomes with virilization, forty-six XY chromosomes with undervirilization, or having both ovarian and testicular tissue;
(2) Received a diagnosis of a disorder of sexual development, in which a physician has determined through genetic or biochemical testing that the individual does not have normal sex chromosome structure, sex steroid hormone production, or sex steroid hormone action for a biological male or biological female; or
(3) Needs treatment for any infection, injury, disease, or disorder that has been caused or exacerbated by the performance of gender transition services, whether or not the services were performed in accordance with state or federal law
Section F: Paperwork
(F) A provider, including a children's hospital, that provides diagnosis and treatment for gender-related conditions is obligated to annually demonstrate compliance with the standards specified in paragraph (B) of this rule using forms and formats approved by the director of mental health and addiction services. This annual compliance demonstration will include, at a minimum, submission of the care plan described in paragraph (B)(3) of this rule.
In addition to this obligation, a provider is also to submit the reports described in rule 3701-3-17 of the Administrative Code to the department of health in accordance with that rule.
Section G: Grandparenting
G) A provider that initiated care to a patient under twenty-one years of age prior to the effective date of this rule is exempt from meeting the standards in paragraph (B) with respect to that patient.
5122-14-12: Private Psychiatric Hospital: Program, Specialty Services, and Discharge Planning
As used in this rule, "biological sex," "cross-sex hormone," "gender reassignment surgery," and "genital gender reassignment surgery" have the same meanings as in rule 3701-3-17 of the Administrative Code.
(5) Medical services shall not include any of the following:
(a) Initiation of any cross-sex hormone or the prescribing, administering, or furnishing of any prescription drug or hormone provided for the purpose of assisting a patient under twenty-one years of age with gender transition that seeks to (i) alter or remove physical or anatomical characteristics or features that are typical for the individual's biological sex, or (ii) instill or create physiological or anatomical characteristics that resemble a sex different than the individual's biological sex;
(b) Any type of medical service for a patient under twenty-one years of age that initiates puberty blocking, including a service involving the prescribing, administering, or furnishing of drugs or cross-sex hormones or the use of other mechanisms to promote the development of feminizing or masculinizing features in the opposite sex; or
(c) Gender reassignment surgery or genital gender reassignment surgery.