Thread by @GBBranstetter

I'm in the federal courthouse in Little Rock for this historic trial. There's no livestream and no electronics allowed once we're gaveled in--I'll be providing updates as possible.

https://twitter.com/ACLU/status/1582001250895556608

We were briefly evacuated for a fire alarm--returning now. Expert testimony is underway.

Lunch break!

This morning the court heard expert testimony from Dr. Dan Karasic, psychiatrist with 29 years experience working with trans people who helped author the two most current standards of care. He estimated the number of trans people he's worked with in the "thousands."

After a brief introduction to the nature of gender-affirming care, Dr. Karasic was asked to respond to arguments made by the state against this care.

Do doctors pressure young people to transition? "It's not our role to tell them who they should be."

Karasic: Patients who have access to care have a "dramatic relief of symptoms...I'm always impressed by the magnitude of improvement from gender-affirming care."

On detransitioning, he said "none" of his thousands of patients had ever done so because of a change in identity.

Karasic: Described a nonbinary patient who started T to lower voice but did not want other effects (body hair, etc). Offered that as typical of patients who begin then stop care.

Noting increase in clinic intakes, Karasic reported no known increase in detransitioning.

Karacik on rise in young people identifying as trans: Noted increase in insurance coverage, growth in access. Relates a call he took in the late 1990s from the wealthy father of a trans kid who literally had a private jet to travel to a provider. Moat families do not.

During questioning by ACLU attorney Leslie Cooper, attorneys for the state made numerous objections to her questioning as "leading," even on basic questions about evidentiary support for standards of care. Judge rejected every objection from the state.

One important update: the trial was initially planned for 8 hours of hearings every business day for two weeks. Per Judge Moody. the trial days will run long while we try to fit as much as we can in a single week. Whatever's left would be heard in December.

After lunch, we returned to Dr. Karasic. Dr. K acknowledged "watchful waiting" approach as really only making sense before puberty. Rejected comparisons between dysphoria/dysmorphia, said latter is more like OCD. Said origins of gender dysphoria have "biological bases"

Lengthy discussion about the supposed ideological rigidity of WPATH. Dr. K noted Kenneth Zucker, for example, still presents at WPATH despite advocating for practices far outside the norm and contrary to the standards of care. Dr. K noted Dr. Z once compared trans kids to dogs.

Asked the impact of stopping gender-affirming care on patients forced to do so, Dr. Karasic described "grave distress" of patients, often resulting in suicide and self-harm occasionally on breasts and genitals. "Really severe suffering" among patients who never start.

Cross-examination of Karasic by the AG's office was...interesting. Lawyer for the state made repeated attempts to have Dr. K explain report from a Swedish medical board that Dr. K is not on to the visible annoyance of the judge. State also used outdated DSM diagnostic criteria.

AG's office: Can you provide a set list of gender identities?

Dr. K: Excuse me?

AG's office: [repeats question]

Dr. K: [Looks to judge]

Judge Moody: You got me confused by this question too

[Back and forth]

Dr. K: "People can have different identities but we only have two diagnoses--adult/child dysphoria."

Dr. K noted gender dysphoria is present "across immigrant cultures, different religious cultures. I've seen people from all backgrounds who have this in common."

Plaintiffs call Dr. Anne Adkins, endocrinologist for 22 years, practiced at the AR Children's Hospital. Has worked with over 600 adolescent trans patients out of thousands of total patients of any kind. Questioned by Chase, she described basic details of puberty blockers and HRT.

Asked about concerns over delaying puberty too long, Dr. A noted puberty has a wide range of start and end points. Noted puberty blockers are most often prescribed to cisgender patients experiencing precocious puberty--some starting puberty as young as 3 without them

Dr. A: Testosterone given to cis adolescents for delayed puberty, hypogonadism, micropenis, post-cancer care. Spironolactone used to treat acne, PCOS. Estrogen used for delayed puberty, Turner syndrome, post-cancer care. Point being these are treatments used beyond dysphoria.

Dr. A: Fertility is only a concern for patients who start puberty blockers at the onset of puberty then move on directly to HRT. Notes only 12 of her patients have taken PB because most don't come out as trans until after puberty is well underway.

Dr. A: Sexual health and satisfaction generally improved by HRT, particularly among patients receiving T (which increases libido). Patients are "much more confident" in dating, seeking romantic partners. Absence of dysphoria and comfort in their body helps.

Asked about adolescent patients of hers who had top surgery, Dr. A notes they were "over the moon." Patients previously on anti-depressant/anxiety medications were able to drop those medications after top surgery. "They can think about the future, they can focus on school."

Dr. Adkins finished her testimony with a story of one of her patients who was in severe distress and arrived after some time in therapy. The teen died by suicide between the initial assessment appointment and second appointment where they would receive HRT prescription.

I'm going to eat dinner then I'll write up the cross-examination of Dr. Adkins

One of the most fascinating things about this trial to me is the state's efforts to recreate trans identities without any input from trans people, rendering themselves incoherent and contradictory. Those gaps became apparent in the cross-examination of Dr. Adkins.

The state had several pointed questions for Dr. Adkins about the difference between someone's gender identity and someone's *perception* of their gender identity--as if GI were some inner node separate from a patient's perception of it. The hearing got wobbly in the metaphysics.

Dr. A: "Everyone has to figure this out whether they're trans or not" notes gender identity conception can begin as early as ages 2-4. For most people, gender identity solidifies around puberty and for a rare few it may shift. Resistant to voluntary/involuntary efforts to change.

Dr. Adkins: "The most important part ia that we're providing the care that keeps them safe and healthy...every patient, I see no matter [whether gender dysphoria or another diagnosis], might see a change in treatment based on what is going on then and there."

State asked "what is gender?"

Dr. A: "Gender is a social construct usually related to sex assigned at birth but also how their family and community are socializing them."

Gender identity is a "core understanding" of yourself; gender is sociologically constructed.

Extensive conversation about adverse effects of puberty blockers and HRT.

State asked about blood clot risks with estrogen; Dr. A said usually followed with other comorbities such as obesity. State went out of their way to note Arkansas has a higher obesity rate.

State: Doesn't an AMAB ("natal boy") somewhat likely to lose the ability to orgasm after prolonged puberty blockers?

Dr. A: Notes AMAB trans femme patients are less likely to want erections. "Some may not even want to orgasm." Noted patient/family informed of these low risks.

Dr. A notes she had a patient taking GnRH's (puberty blockers) at age 24; state seemed perplexed why but nonetheless ended cross. On redirect, Chase ensured she clarified this was a patient also taking HRT; GnRH's are often used in lieu of spironolactone as a stronger T blocker.

Also, there was a point when the lawyer for the state forgot the word "spironolactone."

Tomorrow--more expert witness testimony; may see plaintiff testimony start late tomorrow or early Wednesday.

Good morning! We're starting Day Two of our trial shortly. Today will not be the 12-hour marathon we saw yesterday; we'll be going for a mere ten hours.

Plaintiffs called Dr. Jack Turban (@jack_turban) to provide expert testimony. Dr. Turban is a child/adolescent psychiatrist at UCSF who has 20-30 bylines on peer-reviewed studies. Notes he welcomes disagreement as "a good part of the scientific process"

Dr. T: Lack of randomized trials around HRT/blockers is typical of mental health studies. Randomized trials would raise ethical concerns because it would be choosing to worsen mental health of patients given placebo. Physical effects of HRT couldn't be replicated by placebo.

Dr. T: The bar for adolescent top surgeries is "very high." Patients who receive surgery report lower scores on chest dysphoria with low regret rates (1-2%). Notes studies of trans youth have relatively long follow-up periods relative to other child psychiatric studies.

Dr. T describes the "Dutch protocols," very similar to affirming model used across the US. Notes treatment is scaled up based on irreversibility: social transition to puberty blockers to HRT to surgery. Lack of childhood dysphoria may trigger longer assessment for adolescents.

You may recall Leslie Rutledge telling Jon Stewart 98% of trans youth desist. Dr. T notes this figure is from an older study using looser diagnosis of "gender identity disorder"; included masculine cis girls and feminine cis boys who would not receive a GD diagnosis today.

Dr. T on detransiton: "No consistent definition" and studies use varying definitions, anywhere from temporarily halting medical care to changing name/pronouns to reversion back to a cis identity and gender assigned at birth. Detransition is a "broad, heterogenous term"

Dr T: Those who end medical care more likely doing so because of 1) having achieved desired effects 2) lose insurance 3) medical complications 4) avoiding harassment, stigma, economic penalties of discrimination. Transition regret is a "more specific term" and consistently rare.

Dr T on Rapid Onset Gender Dysphoria (ROGD): Not a recognized clinical diagnosis: "hypothesis" that entered medical literature via Littman 2018 survey of parents only. Failed to speak with trans adolescents who frequently report years of hiding their trans identity.

Dr T: Many parents surprised when child identifies as trans but young people are afraid of poor reactions from their parents.

Does Dr T consider impact of social influence? "We always work to understand patient environment...diagnostic period may be extended based on that"

Asked to respond to state's use of international review reports (Sweden, Finland, NZ, etc), Dr T notes these are literature reviews, none of which are peer-reviewed and none of which support bans on gender-affirming care such as the one at the center of this trial.

Dr. T on potential impacts of ceasing care to young trans people: "These are young people who are really struggling with depression and anxiety, some can't go to school...I'd be left without any evidence-based approaches." Says no other evidence-based models exist.

On cross-examination by the state, Dr. Turban says gender identity has a "strong biological component but the language a patient may use to describe that identity may evolve over time...someone's conception of their gender identity may evolve over time."

Dr. T on discussion of detransition snd desistance in his research/panels: "It's important that we consider all patients and all outcomes" no matter how rare. Internal factors can cause detransition such as shame/internalized transphobia, but "not always a clean distinction"

On his use of data from the 2015 US Transgender Survey, Dr. T notes the USTS was a "convenience sample" rather than a representative sample because rep samples are hard to complete with small minority populations. Notes USTS lived online but completed across in-person events.

At this point the state confuses two different studies on top surgeries, then proceeded to confuse a study on top surgery with a study on puberty suppression.

State eventually asked Dr. T about 13-year-old who received top surgery. Dr T called it an "outlier case"

Dr T on young adolescents and top surgery: "You would need to be quite sure the benefits would be high and the risks of not going forward would be much higher."

Asked about increase in chest dysphoria following testosterone: "T does not have much impact on chest contour"

State asked Dr T about grant he received from AACAP for trans research, noted grant came from pool of funds provided in part by Pfizer. Dr. T notes grants are distributed by an independent panel and researchers are not informed of donors until after research is published.

Plaintiffs call Dr. Armand Antonmaria, a pediatrician and bioethicist at Cincinnati Children's Hospital. Dr. A began with an overview of ethical implications of randomized trials and explaining why a lack of them is not notable for gender-affirming care given ethical issues.

Dr. A: Adolescents are capable of consenting to gender-affirming care. A mental health diagnosis does not "intrinsically impair medical decision-making capacity" on the part of the patient. Rejects accusation gender-affirming care is "experimental" as the state law calls it.

Dr. A: "Not aware of any randomized control trials on provision of therapy alone" to treat dysphoria. Notes systematic reviews of the literature do not make recommendations as a matter of course. Provides overview of minor risks from blockers (bone density) and HRT (blood clots)

Dr. A: The risks raises by blockers or HRT for dysphoria are "not categorically different" from comparable pediatric treatments.

What other reasons might an adolescent receive chest surgery? "Gynecomastia, deformities in the chest wall, AFAB breast reduction/augmentation"

Dr. A: Chest surgeries performed on cis adolescents are "in general performed in order to change the appearance of the chest." Top surgery for trans teens carries comparable risks (bleeding, asymmetrical appearance, etc). Brief discussion of pectus excavatum (rare complication).

Act 626, like all proposed bans on trans care, exempts surgeries performed on intersex infants.

Dr. A notes surgeries are performed on "young children and infants at ages in which patient is incapable of consent." Evidence supporting necessity of such surgeries is "very low"

Dr. A: "A substantial minority" of intersex patients who received surgery as infants report poor outcomes over lifespan including "loss of sensation." Notes intersex health is an "ongoing discussion" in medical field and growing list of institutions are rejecting infant surgery.

Dr. A: Treatments being used "off label" does not mean a lack of evidence or such treatments are "experimental." Notes pediatric medicine is more frequently off-label: 30% of all interactions with a pediatrician result in an off-label course of treatment.

Dr. A: Act 626 "puts providers in the untenable situation of not providing best-practice medical care or risk losing their license." Says he is not familiar with any evidence of "consistent unprofessional behavior" among providers of gender-affirming care.

State witnesses will argue WPATH is compromised by having non-medical trans experts on draft committees. Dr A notes full membership is restricted to medical experts with clinical experience, but "10-15%" of draft committees are "other stakeholders" including patient advocates.

Dr. A says SEGM "is not clear and transparent in regards to its membership." Notes many members of SEGM's leadership lack expertise in gender-affirming care; one is an evolutionary biologist and another is an ethicist on chemical warfare.

State's cross examination of Dr. A was brief. At one point they asked him to speculate about whether FDA would approve testosterone treatments if it was previously banned for off-label use. Dr. A notes such a hypothetical is impossible because off-label use is how we know T works

We're on a brief intermission while we wait for our first plaintiff: Donnie Ray Saxton, father of 17-year-old trans son Parker Saxton. aclu.org/legal-document…

Fundamentally this case is about families fighting for the lives of their children and their right to call Arkansas their home. That they and their children are forced to do so is an avoidable travesty. Nonetheless, the strength of these families is evident to the court.

Donnie Ray Saxton is a father of five ranging in ages from 14 to 22 years old from Vilonia, Arkansas. He operates a plumbing business his family has owned and operated for 31 years. Asked if his family is involved in the community, Donnie replied "holler if you need us."

Donnie's son Parker is 17 and a senior in high school--a "cool kid." He is active in choir and volunteer work in Vilonia. Parker first came out as transgender in "a heartfelt letter" in 2019. "It was a long letter, but a good read. A lot of things [about Parker] became clear."

Donnie was "pretty relieved and hopeful but not surprised." Parker had always dressed more masculine and cut his hair short. At some point Donnie realized Parker was binding using multiple sports bras before coming out as trans. Refused to wear a dress for choir.

Parker grew more withdrawn after puberty, "wouldn't answer the phone from his best friends." Parker tacked a towel over his bathroom mirror to avoid his reflection. Parker hasn't used a public restroom since pre-school. Donnie notes he "had no idea" what transgender meant.

After multiple visits with a mental health counselor, Parker was referred to the Gender Spectrum clinic at AR Children's Hospital in June 2020. After an initial intake visit with just Donnie, he and his son Parker saw Dr. Michele Hutchison (also a plaintiff in this case).

Donnie: Dr. Hutchison was "very open and hospitable to us." Parker had "a lot of anxiety around his menstrual cycle" and was prescribed Depo-Provera. Dr. H introduced risks/benefits of Depo, but Donnie's younger daughter was already on them so had few concerns.

Donnie: Impacts of ceasing menstruation were immediate and positive, but depression remained and Parker continued to avoid his reflection. Parker expressed interest in testosterone "3 to 4 months after first visit...after talking to everyone, I really wanted to give it a try."

Dr. H ordered blood work, pregnancy test, and psychological evaluation before prescribing T. Parker began T in May of 2021 as the state was passing the ban on gender-affirming care. Parker "was so withdrawn" because of the bill. "I assured him we would figure it out."

After starting T, Donnie saw "a complete turnaround" in Parker's mood. "Truly amazing. He's got huge confidence! [Chuckling] Almost too much just like his old dad."

Confidence was so great Parker volunteered to read the names of fallen First Responders at a local 9/11 memorial.

Donnie: "We're a family, and we're not a family without Parker. We'd have to pick up and leave [if state's ban took effect]. This is home. Our small town transitioned with us."

What would happen if Parker lost this care?

"I'm not going to think about that."

The state declined to cross-examine Donnie.

Next up is Aaron Jennen, father of three from Fayetteville. Aaron serves as a US Attorney since 2014 and was a former prosecutor. His wife Lacey chairs the Urban Forestry Advisory Board in Fayetteville and he has siblings, nieces, and nephews across NW AR. aclu.org/legal-document…

His daughter Sabrina is 17-years old and first came out as trans at 15. Aaron describes his daughter as "smart, gifted, beautiful...has easily the most envied hair in the court room." Sabrina loves DMing for her DnD group and plans to go to college for either art or nursing.

When Sabrina told Aaron and Lacey she was trans, Aaron "knew that was a big parenting moment and I didn't want to screw that up." Says Sabrina had previously always worn a shirt while swimming and avoided public restrooms, other issues "we'd initially chalked up to quirks."

Aaron: "We wondered 'does she know what that really means?'...Our overriding concern was for her safety in her community and among her peers. Would she be bullied? Harassed? Or worse?"

After coming out Sabrina grew her hair, dressed androgynously, and requested she/her pronouns.

Aaron eventually helped Sabrina legally change her name. After 3 months of meeting with a counselor, Sabrina was referred to Dr. Stephanie Ho for assessment for HRT. "If it'd been up to Sabrina" she would've started right away, but Aaron/Lacey wanted to learn more.

Aaron: A medical transition "gave us more pause and hesitation" than Sabrina's social transition. After consulting with Dr. Ho, Sabrina began HRT in December 2020.

Aaron compared Dr's efforts to inform them of HRT to previous incident another child had their adenoids removed.

Aaron: Sabrina "is doing great. Dysphoria has almost entirely dissipated. She loves having her picture taken, taking selfies."

Confidence grew after starting HRT. Sabrina "put her name in the hat to be homecoming queen this year."

Aaron: Act 626 greatly concerns him. "Sabrina not receiving treatment is not an option...state is forcing us to travel outside the state and [gesturing to lawyers for the state] as I'm sure they know being a government attorney doesn't pay that well."

Aaron began to sob on the witness stand. "The other option would be leaving Arkansas. I'm sorry. I believe ending treatment would be a detriment to my loving, thriving child."

Aaron looked at Sabrina across the court room. "I promise you that will not happen."

The state declined to cross-examinr Aaron.

After some procedural issues around deposition testimony and legislative evidence, plaintiffs noted they have no more witnesses for today but will have some tomorrow. The state also has no more witnesses; court adjourned until tomorrow

Good morning, and welcome to Day Three of our trial.

The first witness this morning will be Dr. Michele Hutchison, founder of the Gender Spectrum clinic at Arkansas Children's Hospital. You may remember her testimony against the state's ban.

https://twitter.com/ACLU/status/1375953530142478338?t=ecrem2n9fEgJm1F3XvD7UQ&s=19/video/1

Dr. Hutchison is a board certified pediatric endocrinologist with faculty experience at UT-Southwestern, Medical Center of South Carolina, and six years at the University of Arkansas Medical Center/Arkansas Children's Hospital ending July 2022. She is now at Univ. of New Mexico.

Dr. H and a team at ACH led the creation of Gender Spectrum in February 2018. Colleagues across Arkansas expressed a strong need for a centralized provider of gender-affirming care; providers in surrounding states said AR families were traveling hundreds of miles to access care.

Dr. H: Clinic's protocols were developed in consultation with other providers, WPATH, and Endocrine Society. Gender-affirming treatments ranged from counseling to menstrual suppression, puberty suppression, and HRT. Same meds used for precocious puberty, PCOS, Turner's syndrome

Dr. H: Gender Spectrum saw 320 patients in her time, and she saw majority personally at least once. No "single treatment plan" for trans patients;"individualized care" with "team" approach. If any member of team (including parents) objects to treatment plan, plan is revised.

Dr. H: Average age of patients at intake was 16. Very few prepubertal patients and only 4 patients were prescribed puberty blockers. Minimum age requirement to begin HRT was 14. Most were referred by PCP or existing therapist; some by word of mouth.

Dr. H: Assessment for treatment included family and personal health history, psychosocial assessment, social support assessment, history of gender presentation/identification. For HRT included blood panel, metabolic panel, persistent/consistent IDing. No surgery offered at GS

Dr. H: Family/parents informed at every step of assessment and risks/benefits of treatment. Trans patients often avoided mirrors, showers, locker/changing rooms. Patients usually had history of anxiety/depression, self-harm, suicidal ideation before starting treatment.

Dr. H: After starting HRT, patients reported better overall mold, better relations with parents/siblings/peers, higher academic performance. "Very rarely did I ever have a patient talk about their future" at assessment. After HRT "they start talking about college, career plans."

Better overall mood* (apologies)

Dr. H: Patients who began HRT could often decrease anti-depressant dosage or drop altogether. Vast majority saw improvement, but "we always had a few stoic kids...these are teenagers."

Some still struggle: "Being a teen is hard, being trans is hard, being both is hard."

Dr. H: Patients and families informed medical transition will not resolve every mental health problem or all dysphoria. Overall patient satisfaction was very high; a few complications included slight uptick in cholesterol, blood pressure. Sometimes required adjust in dose/method.

Dr. H: No Gender Spectrum patients ever medically detransitioned. Two patients who arrived at clinic thought they may be trans; counseling and assessment cleared them and they never accessed medical treatment.

GS patients often return after aging out to express gratitude.

Dr. H: Act 626 has her "generally worried that we're going to lose some kids." Introduction of bill sparked "panicked calls" from families/patients. Four of her patients were hospitalized for suicide attempts within days; at least "a few others" were across Arkansas.

Dr. H: Mental health screen at clinic saw overall anxiety scores climb from 40% of new patients to 60% in wake of Act 626.

Dr. H then reviewed intake and benefits for youth plaintiffs Dylan Brandt, Parker Saxton, and Brooke Dennis. State began cross-examination before lunch.

Cross-examination of Dr. H was mostly confidential given it touched on personal medical information of some of the plaintiffs.

Plaintiffs called Dr. Kathryn Stambough, current medical director of the Gender Spectrum clinic and clinical OB/GYN at AR Children's Hospital.

Dr. S was raised in Little Rock and studied medicine in Missouri. Alongside her work at Gender Spectrum, she is also a practicing OB/GYN and works at the InStep program for intersex youth. She joined Gender Spectrum in August 2020 after Dr. H left. GS has 248 active patients.

Dr. S confirmed much of Dr. H's testimony about protocols at Gender Spectrum. Asked if any GS patients have medically detransitioned, Dr. S confirmed zero had. Would such a patient find support at Gender Spectrum? "Absolutely."

Dr. S: One patient excelled at school and art before puberty; performance declined as puberty started. Another was gravely depressed before starting HRT; "Her mother was really surprised she survived" without it.

Dr. S: Another patient had no less than six suicide attempts before starting HRT; none since starting. Yet another was suffering at school because voice dysphoria led them to refuse to speak; patient is now "flourishing" since starting testosterone.

Dr. S: Since January 2022, Gender Spectrum sees new patients but does not begin new patients on GnRH's or HRT. 44 new patients have joined the clinic, but none have found HRT at other providers in Arkansas despite law being blocked by injunction.

Dr. S: Families "are not doing well" since Act 626 but "holding out hope." Many have socially transitioned and legally changed names. "Many have only been known to their communities as their gender identity." Expressed strong safety concerns for patients.

Asked why patients can't just wait until their 18, Dr S: "We cannot minimize the impact of waiting. I'm not being hyperbolic when I say some patients will not make it to 18."

Dr S: Consults on fertility options for patients (including egg/sperm freezes) but few opt for them.

Dr S: "Very close" relationship with patients. "An amazing privilege and honor...the share life achievements, school updates, art...we're on that journey with them."

Some patients are not out as trans, including a few closeted to members of extended family.

Dr. S: Harassment is unfortunately routine among her patients. One adolescent patient had peers write hateful messages in chalk along the route they walk to school.

Dr S on Parker Saxton, who's father testified yesterday: "Before T, there was no future. No 'next' in his life."

On cross, state asked Dr. S about differing risks of puberty blockers/HRT in trans vs. non-trans patients. On bone density risks of PBs, Dr. S points out bone density risks are greater in non-trans endo patients who do not go on to HRT (which helps recover bone loss).

Discussion between the state and Dr. S about sperm/oocyte cryopreservation. State notes auch methods do not 100% ensure future fertility options. Continuing trend of state emphasizing relative fertility risks.

Plaintiffs call Amanda Dennis, mother of 10-year-old Brooke Dennis. The Dennis family and their three children moved to Bentonville, AR in the spring of 2020. Amanda works in ad-tech at Walmart corporate. Describes Brooke as "one of the most incredible humans I know."

Amanda: Brooke loves to draw, make up stories, play Roblox. Brooke had "gravitated towards traditionally feminine things." When the realtor of their new home gifted them a family portrait, photographer referred to Brooke using she/her pronouns which Brooke loved.

Amanda: "We were happy we were such loving parents to all of our children that she would share that with us." Brooke loved to pretend to be Elsa from Frozen; would take t-shirts and towels to simulate a ponytail. Became upset when others referred to her as a boy.

Amanda: "Brooke didn't get to experience the daily joy that kids should experience" before socially transitioning. Chose Brooke (Amanda's middle name) as her new name. Local pediatrician referred Brooke to Gender Spectrum in October 2020; told to watch for signs of puberty.

Amanda: No medical options for Brooke since she is prepubertal, but "we all know puberty is getting closer." Brooke watching 14-year-old brother and is gravely distressed. Worries about Adam's apple, lowered voice. "I'm going to do what I need to do to ensure my child grows up."

Amanda: "I've always promised all of my children that we will care for you...it fills me with so much sorrow that this would happen where I live."

Brooke being forced into male puberty "is hard for me to think about...it's hard to allow myself to think about what could happen."

Amanda: If Act 626 is enforced family will need to find provider in Colorado, "somewhere she feels like she can establish a relationship" with provider. Moving is also an option, but complicated. Amanda's Father in Law has Parkinson's; relocating work requires CEO approval.

Amanda: Our three children "don't want to leave AR." Oldest is a high school freshman. Amanda's widowed mother lives in AR.

"We should be focused on raising our kids and helping them grow into adults."

Plaintiffs call Joanna Brandt, mother of 17-year-old Dylan Brandt and two others. Joanna is a small business owner from Greenwood, AR. Joanna tells the court Dylan "always gravitated towards masculine clothes" and appearance. As a child he enjoyed mud puddles and football.

Joanna: Dylan came out as transgender at age 13 in a letter signed "Dylan." She "made sure he knew he was loved and supported" no matter what. "I was trying to wrap my brain around it. As a parent, I'm concerned anytime anything new comes up."

Joanna: "I was mostly concerned how this would go over in our small town." Dylan expressed strong chest dysphoria, mostly wore baggy clothes after start of puberty. After coming out Joanna took her son shopping for clothes, "brought him a level of comfort" he was lacking.

Joanna: Soon Dylan began to be gendered as male by strangers, recalls someone saying "thank you sir" when Dylan held the door for them.

Dylan had his first appointment with Gender Spectrum in January 2020. Received a Depo shot that day with Joanna's consent.

Joanna: "Lots of questions" for Dr. Hutchison at intake. Dylan expressed desire for testosterone almost immediately. Dylan and Joanna met with a psychiatrist to discuss T treatments, risks, benefits. Psych, Dr. H, and Joanna determined T "would be appropriate course of treatment"

Joanna: Dylan's face changed "a lot" in his first year on T. "He looks a lot like my dad did."

Dylan had been "holding his breath for years and he could finally exhale" on testosterone. "The deeper the voice got, the thicker the beard got--he just lit up."

Joanna: "His capacity for empathy for others--but more importantly for himself--has been remarkable. Dylan is the most emotionally intelligent person I know...The kid that Dylan was would not be in this courtroom today. It is because of this care he is able to fight for himself."

Joanna: Act 626 "has me very concerned for Dylan...not only would he lose this care, he would know it was taken from him."

Discussion about traveling is "very hard." Moving is also difficult but seems more likely course of action should 626 be enforced by the state.

Joanna: "I don't even know how we would manage" if 626 goes into effect. "I'm a pretty resourceful person, but it would difficult." Financial impact of relocating would be "huge...I don't have a college degree to fall back on. I'd be forced to sell the home I own."

17-year-old Dylan Brandt, the chief named plaintiff in this case, takes the stand. Dylan lives in Greenwood with his mother and is a junior in high school with a part-time job. He is the only transgender person who will testify in the entire trial.

Dylan: "It was pretty hard" being seen as a girl before coming out. "It didn't feel right but I didn't know why it didn't feel right." He dreaded puberty but felt "there was nothing I could do about it." Dylan refuses photographs, and refused to smile in the few he took.

Dylan: "Mom was very supportive right off the back." Family took to new name and pronouns "right away." When he received his first Depo shot in January 2020, "I had some hope. Felt like I had pressure released," but remained dysphoric in other ways.

Dylan: Starting testosterone was "the best feeling...I've grown so much. I'm more confident, happier with myself." Notes he took yearbook pictures for granted but feels so much pride looking at them now. "I still have my days, but my life has changed so much for the better."

Dylan fears for his safety in Arkansas. "Being a trans kid in the south, some people make it very well-known I'm not welcome here." Says he is always "looking over his shoulder" at school.

Stopping T would be "very hard...the thought of going back is just not an option."

Dylan: "We'd probably have to leave the state" if Act 626 goes into effect. "I have a job, my mom has a business. I still have a year and a half of high school left. Being pushed out of the place I've lived my entire life is hard."

Despite this, Dylan remains "hopeful."

The plaintiffs have no more witnesses and rest their case.

No hearing is scheduled for tomorrow. On Friday, the state will call three witnesses to start the defense. After that, trial will resume after Thanksgiving. Judge has atrong desire to keep state to same length of time.