Tweets mentioned a “ban on gender affirming care” for youth or minors in the state of Florida, but did not mention any specific law by name.
On May 15 2023, we published a fact check covering a spate of new laws in the state of Florida, which primarily focused on emergency medicine and concluded:
A viral May 13 2023 tweet by Alejandra Caraballo asserted that Florida Governor Ron DeSantis “just signed the ‘Let Them Die Act’ which allows medical professionals to refuse to treat patients, even if it puts their lives at risk”; in a follow-up tweet, Caraballo provided the name of the legislation.
DeSantis issued a May 11 2023 press release that confirmed he signed the legislation into law. The bill enabled any healthcare provider or payor to refuse to treat Florida residents on the basis of the entity’s purported beliefs. An early amendment excluding “life supporting care” did not appear in the version DeSantis linked, which held that a section “may not be construed to override any requirement to provide emergency medical treatment in accordance with state law or the Emergency Medical Treatment and Active Labor Act.”
As is often the case with political claims in Florida, we located additional information on the website FloridaPolitics.com. On June 6 2023, the site covered Judge Robert Hinkle’s ruling and identified the specific state law, SB 254:
A federal judge issued a narrow order Tuesday [June 6 2023] blocking a new state law (SB 254) and rules that prevent minors not currently in treatment from obtaining “puberty blockers.”
U.S. District Judge Robert Hinkle’s ruling only applies to three minors whose parents sought an immediate block to Florida’s ban on gender-affirming care, but the action signals that the law itself could eventually get struck down.
In his 44-page ruling, Hinkle pushed back on the assertions made by attorneys defending the ban — which was pushed by the administration of Gov. Ron DeSantis and Surgeon General Joseph Ladapo.
In his order, Hinkle took aim at criticisms of the medical organizations in the United States that have endorsed gender-affirming care. The American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association, American Psychiatric Association, and at least a dozen more medical organizations have endorsed the care, Hinkle noted.
The New York Times analyzed Hinkle’s ruling on June 6 2023, reporting:
A federal judge in Florida issued a scathing assessment on [June 6 2023] of the state’s ban on gender transition care for minors, asserting in a ruling that the families with transgender children who sued the state are “likely to prevail on their claim that the prohibition is unconstitutional.”
Judge Robert L. Hinkle of Federal District Court in Tallahassee ruled specifically that three transgender children can be prescribed puberty blockers despite the new state law, which also adds new hurdles for adults who seek similar care.
But as legal challenges have been mounted to new restrictions on transition care that have been enacted across the country, Judge Hinkle’s ruling exemplifies the kind of chilly reception that the bans may receive from judges.
“Gender identity is real,” Judge Hinkle wrote, adding that “proper treatment” can include mental health therapy followed by puberty blockers and hormone treatments. “Florida has adopted a statute and rules that prohibit these treatments even when medically appropriate.”
Politico.com published an article about Hinkle’s “stinging rebuke to Florida Gov. Ron DeSantis and the Republican-controlled Legislature,” adding:
U.S. District Judge Robert Hinkle on [June 6 2023] blocked the state from applying the ban to three minors whose parents are part of an ongoing lawsuit, saying they would “suffer irreparable harm” if they were not allowed to continue access to hormones and other types of treatment.
That reporting linked directly to a copy of Hinkle’s injunction (“Jane Doe et al. v. Joseph A. Ladapo et al.”), hosted on Politico.com. “I. Background: the parties, record, and motions” on the injunction’s first page identified the plaintiffs and defendants, articulating urgency with respect to the injunctive relief sought by the plaintiffs:
Each of the seven plaintiffs is the parent of a transgender child on whose behalf this action is brought. Three have moved for a temporary restraining order and preliminary injunction. One child’s doctors say she needs GnRH agonists now, without delay; doctors for the other two say they will need GnRH agonists soon. The needs of the other plaintiffs’ children are less immediate, so they have not joined the emergency motions.
The defendants are the Florida Surgeon General, the Florida Board of Medicine and its members, the Florida Board of Osteopathic Medicine and its members, the Florida Attorney General, and each of Florida’s 20 State Attorneys. The individuals are defendants only in their official capacities. This order refers to the Surgeon General, the Boards, and their members as the “medical defendants.” The order refers to the Attorney General and State Attorneys as the “lawenforcement defendants.”
Subsequently, Hinkle explained necessary conditions to meet the requirements for the issuance of a preliminary injunction in “II. Preliminary-injunction standards.” In this action, the plaintiffs first had to prove they would “suffer irreparable injury” in the absence of injunctive relief:
As a prerequisite to a preliminary injunction, a plaintiff must establish a substantial likelihood of success on the merits, that the plaintiff will suffer irreparable injury if the injunction does not issue, that the threatened injury outweighs whatever damage the proposed injunction may cause a defendant, and that the injunction will not be adverse to the public interest.
A third section — “III. Gender identity is real” — started to form the “rebuke” described on social media:
With extraordinarily rare exceptions not at issue here, every person is born with external sex characteristics, male or female, and chromosomes that match. As the person goes through life, the person also has a gender identity—a deeply felt internal sense of being male or female. For more than 99% of people, the external sex characteristics and chromosomes—the determinants of what this order calls the person’s natal sex—match the person’s gender identity.
For less than 1%, the natal sex and gender identity are opposites: a natal male’s gender identity is female, or vice versa. This order refers to such a person who identifies as female as a transgender female and to such a person who identifies as male as a transgender male. This order refers to individuals whose gender identity matches their natal sex as cisgender.
The elephant in the room should be noted at the outset. Gender identity is real. The record makes this clear. The medical defendants, speaking through their attorneys, have admitted it. At least one defense expert also has admitted it. That expert is Dr. Stephen B. Levine, the only defense expert who has actually treated a significant number of transgender patients. He addressed the issues conscientiously, on the merits, rather than as a biased advocate.
Despite the defense admissions, there are those who believe that cisgender individuals properly adhere to their natal sex and that transgender individuals have inappropriately chosen a contrary gender identity, male or female, just as one might choose whether to read Shakespeare or Grisham. Many people with this view tend to disapprove all things transgender and so oppose medical care that supports a person’s transgender existence. In this litigation, the medical defendants have explicitly acknowledged that this view is wrong and that pushing individuals away from their transgender identity is not a legitimate state interest.
Section three continued, providing examples of conflict between “proponents” of the law at issue and scientific consensus. Hinkle concluded the section, stating:
Any proponent of the challenged statute and rules should put up or shut up: do you acknowledge that there are individuals with actual gender identities opposite their natal sex, or do you not? Dog whistles ought not be tolerated.
A fourth section examined the statute. In “V. The standards of care,” Hinkle took care to outline a consensus on a standard of care, correctly stating that the treatment at issue was available “only to adolescents or adults, never younger children”:
There are well-established standards of care for treatment of gender dysphoria. These are set out in two publications: first, the Endocrine Society Clinical Practice Guidelines for the Treatment of Gender Dysphoria; and second, the World Professional Association for Transgender Health (“WPATH”) Standards of Care, version 8.13 I credit the abundant testimony in this record that these standards are widely followed by well-trained clinicians. The standards are used by insurers and have been endorsed by the United States Department of Health and Human Services.
Under the standards, gender-dysphoria treatment begins with a comprehensive biopsychosocial assessment. In addition to any appropriate mental-health therapy, there are three types of possible medical intervention, all available only to adolescents or adults, never younger children.
A focus on medical consensus continued in the fifth section. In it, Hinkle noted that no credible medical organizations “has taken a contrary position” to the accepted standard of care articulated throughout.
Hinkle also said that “no rational basis” existed for a “ban” on the targeted treatments,” adding that the defendants produced “no evidence” in support of their claims the treatments were harmful:
The overwhelming weight of medical authority supports treatment of transgender patients with GnRH agonists and cross-sex hormones in appropriate circumstances. Organizations who have formally recognized this include the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association, American Psychiatric Association, and at least a dozen more. The record also includes statements from hundreds of professionals supporting this care. At least as shown by this record, not a single reputable medical association has taken a contrary position.
These medications—GnRH agonists, testosterone, and estrogen—have been used for decades to treat other conditions. Their safety records and overall effects are well known. The Food and Drug Administration has approved their use, though not specifically to treat gender dysphoria.
The clinical evidence would support, though certainly not mandate, a decision by a reasonable patient and parent, in consultation with properly trained practitioners, to use GnRH agonists at or near the onset of puberty and to use cross-sex hormones later, even when fully apprised of the current state of medical knowledge and all attendant risks. There is no rational basis for a state to categorically ban these treatments.
The record includes no evidence that these treatments have caused substantial adverse clinical results in properly screened and treated patients.
Hinkle’s injunction clocked in at 44 pages in total, and it delved deeply into the medical and legal concepts at issue in the ruling. In “XIV. Conclusion,” he granted the plaintiffs’ request for injunctive relief, and wrote:
Gender identity is real. Those whose gender identity does not match their natal sex often suffer gender dysphoria. The widely accepted standard of care calls for evaluation and treatment by a multidisciplinary team. Proper treatment begins with mental-health therapy and is followed in appropriate cases by GnRH agonists and cross-sex hormones. Florida has adopted a statute and rules that prohibit these treatments even when medically appropriate. The plaintiffs are likely to prevail on their claim that the prohibition is unconstitutional. And they have met the other prerequisites to a preliminary injunction.
The plaintiffs thus are entitled to a preliminary injunction of appropriate scope. Federal Rule of Civil Procedure 65(c) requires a party who obtains a preliminary injunction to “give security in an amount that the court considers proper to pay the costs and damages sustained by any party found to have been wrongfully enjoined.” This order requires the plaintiffs to give security for costs in a modest amount. Any party may move at any time to adjust the amount of security.
On June 6 2023, Florida Judge Robert Hinkle issued an injunction with respect to Florida’s recent ban on gender-affirming care for minors and adults. In the injunction, Hinkle plainly identified the legislation’s absence of merit on legal and medical grounds, and granted the plaintiffs the relief they sought — continued access to gender affirming care. Hinkle’s injunction included an opinion that the plaintiffs were “likely to prevail on their claim that the prohibition is unconstitutional.”