Luis Casas, a pediatric endocrinologist suing North Dakota over its ban on gender-affirming care for minors, testifies in court on Jan. 30, 2025. (Mary Steurer/North Dakota Monitor)
Editor’s note: If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”
By: Mary Steurer
BISMARCK, N.D. (North Dakota Monitor) – A pediatric endocrinologist said one of his patients attempted suicide after learning North Dakota had criminalized gender-affirming care for minors.
The adolescent had been diagnosed with gender dysphoria and planned to pursue medical treatment, the doctor said, only to discover it was no longer an option because of a law approved by legislators in 2023.
“This adolescent ended up in multi-organ failure,” Luis Casas told a courtroom on Thursday. “Had to be flown to the Cities where they were in the ICU for several weeks, and hospitalized for what ended up being at least a couple of months.”
An attorney asked Casas how he knows the suicide attempt was related to the health care law.
“Because they told me,” he replied.
Casas is the sole plaintiff in a lawsuit challenging the ban, which makes it a crime for health care professionals to provide gender-affirming care to anyone under 18. He’s bringing the case on behalf of himself, as well as his current and future patients.
Casas alleges the ban violates personal autonomy and equal protection rights under the state constitution.
“There’s no other area in my specialty where an individual or a family, or a parent or a guardian, doesn’t have the ability to decide on what to do,” he said on the witness stand Thursday.
Attorneys for the state counter that gender-affirming care is an emerging area of medicine, and that North Dakota lawmakers are within their rights to regulate it.
Casas was the last of a dozen witnesses to testify for the plaintiffs in a trial to decide the ban’s fate. The court will hear testimony from the state’s witnesses starting Friday.
Transgender young people in North Dakota are at a much higher risk for suicide than their peers, according to an analysis of the 2023 North Dakota Youth Risk Behavior Survey by suicide prevention advocate Faye Seidler and the Harbor Health Initiative.
Roughly 74% of transgender middle schoolers in who took the survey said they had seriously considered suicide — almost four times as many as their straight peers. About 40% of transgender high schoolers said they had seriously considered suicide, about three times as many their straight peers.
Casas told the courtroom that withholding gender-affirming treatments from transgender adolescents can be catastrophic to their mental health.
“You’re subjecting this adolescent to a childhood of living in a body that is not consistent with their gender identity,” he said of the law. “I think it’s simply cruel.”
Casas said he’s lost patients to suicide before. All of them were transgender, he said.
Three North Dakota families with transgender children were previously plaintiffs alongside Casas, but South Central Judicial District Judge Jackson Lofgren ruled earlier this month that they don’t have standing to bring the challenge. Some of the former plaintiffs — including two teens who see Casas for gender-affirming care — testified in the trial earlier this week.
The ban contains an exemption for children who were receiving care before it went into effect.
Despite this, Casas said he does not provide gender-affirming treatments to any minors in North Dakota, even those who fall under the exemption, for fear of prosecution. These patients must travel to Moorhead, Minnesota, to see him.
Casas testified that there aren’t any unique risks to prescribing puberty blockers and hormone therapy to treat gender dysphoria. He continues to prescribe these medications to adolescents for other medical conditions, like precocious puberty and hypogonadism.
He said his patients must be diagnosed with gender dysphoria before they can be eligible for gender-affirming care.
He also goes to lengths to make sure patients understand the treatments, he said. That includes giving his adolescents and their family members what he called “informed consent forms.”
“It goes through all of the potential changes that happens to the body as a result of this treatment, and it specifies what aspects of those changes could be reversible if we were to stop treatment, what parts of these treatments may be partially reversible or be fully irreversible,” he said.
He acknowledged that not all young people with gender dysphoria need gender-affirming medical care. For some transgender people, social transitioning — like changing one’s clothes, pronouns or name to conform with one’s gender identity — is enough.
Casas said if there isn’t consensus between him, a patient and their family that medical treatment is the right option, they don’t proceed. He said he hasn’t had any patients tell him they regret gender-affirming treatments.
There aren’t any medications approved by the U.S. Food and Drug Administration specifically for treating gender dysphoria in minors.
Attorneys for the defense have underlined during the trial that compared with some other medications, there isn’t a lot of long-term, comprehensive research demonstrating that puberty blockers and hormone therapy are safe and effective for transgender adolescents.
Casas didn’t dispute this but also maintained that this wasn’t a reason to abandon the treatment.
For one, it’s common for doctors to prescribe medications for so-called “off-label” uses, especially for minors, he said.
Other experts for the plaintiffs testified this week that robust pharmaceutical research can be limited by many factors, including funding incentives and the complicated ethics of testing medication on patients.
“In child and adolescent psychiatry and in pediatrics, generally speaking, you cannot have strong, high-level evidence, because it’s not possible,” said Gabriela Balf, a psychiatrist who has experience diagnosing gender dysphoria in adolescents. Balf previously lived in Bismarck but moved out of state because of the law.
She said existing research, as well as her own experience helping kids transition, shows the treatment works.
“Overall, kids get their life back,” Balf said. “They start talking again. They socialize. Previously they would stay home and lose years of school.”
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