Dylan Brandt and his mom, Joanna Brandt, have both testified in Brandt v. Rutledge, a challenge to Arkansas's ban on gender-affirming care for trans youth.

The state’s first big-name expert witness in the trial over Arkansas’s ban on gender-affirming medical care for youth was an odd choice, considering psychiatrist Stephen Levine believes such care is sometimes necessary and in fact has prescribed it himself.

Levine also testified that, if Arkansas’s Act 626 does take effect, doctors should continue treating young people already on hormone therapy and just take their chances if they get caught and hauled up before the state medical board.

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It was a wacky kickoff to the second week of a trial to determine the fate of the first-in-the-nation ban on gender-affirming care for transgender youth. The trial got back underway Monday, after U.S. District Judge James Moody‘s tight schedule required an unusual 5-week intermission.

The plaintiffs — four young transgender Arkansans, their families and one of the doctors who provides puberty blockers and hormone therapy at Arkansas’s only clinic gender clinic serving people under 18 — made their case Oct. 17-21 with the help of a team of attorneys from the American Civil Liberties Union. During that first week, a psychiatrist, a pediatric endocrinologist and a bioethicist with experience studying and treating transgender youth presented evidence to show gender-affirming care is scientifically indicated and in many instances lifesaving for young people struggling with gender dysphoria. Family members of trans youth and Dylan Brandt himself, namesake of this Brandt v. Rutledge suit, testified to the profound and life-changing benefits they experienced with gender-affirming medical care.

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On Monday, the state kicked off what’s expected to be four full days of testimony in  defense of Act 626. Passed during the Arkansas legislature’s culture war inferno of 2021, Act 626 bans gender-affirming medical care for youth in Arkansas and punishes doctors who try to refer young transgender patients elsewhere. Conservative Republican Governor Hutchinson vetoed the law, saying it went too far, but the supermajority Republican legislature overrode the veto. The Eighth Circuit upheld Judge Moody’s injunction keeping the law from going into effect as the Brandt v. Rutledge trial was pending.

Michael Cantrell from the Arkansas attorney general’s office spent most of the day with Levine on the witness stand, where Levine testified that gender-affirming care is doled out too easily as a quick fix that young people may later regret.

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An Ohio psychiatrist who started his medical career in 1970 specializing in sexual dysfunction, Levine is a popular courtroom expert who has provided expert testimony on behalf of prison systems denying gender-affirming care for inmates and school systems denying a spot on the team for transgender athletes. Levine is a well-known defender of conversion therapy, and his reputation as a paid gun for anti-trans causes has earned him plenty of scrutiny and mocking.

Clinicians are too quick to begin trans-sex hormones or green light surgical interventions for young transgender people, Levine said during his nearly seven hours of testimony. During his career at Case Western Reserve University and in private practice, Levine said he’s seen “a dramatic and poorly explained rapid increase in the number of people with gender dysphoria.” When he began his medical career, Levine said most transgender patients were people labeled male at birth who wanted to live as females. Now, he said, more labeled female at birth are making gender transitions*.

Levine suggested social contagion, exposure to transgender people on the internet, confusion about rapidly evolving ideas about gender roles, early psychological trauma and run-of-the-mill anxiety about the body’s changes during puberty may be behind the rising numbers.

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Encouraging young people who experience gender dysphoria to transition to a different gender identity is homophobic, he said, because maybe those kids are just gay. “What we’re really doing is interfering with the natural development of homosexual orientation,” he said. This outdated opinion, along with some other vintage views he shared from the witness stand Monday, puts Levine far out on the fringe of the medical community.

The 80-year-old doctor referred to transgender people who become sterile as the result of gender-affirming medical care as being “medically fixed,” and suggested they could face a life of sexual dysfunction partly because the pool of people who will be sexually attracted to them is smaller. He suggested a young boy might think he wants to become a girl when really he just wants to express his feelings more freely, or wear pink.

The American Academy of Pediatrics, the American Medical Association and the American Psychiatric Association slingshotted past these debunked theories in the 1980s or so, and today they all actively advocate for access to gender-affirming medical care for youth. Every major reputable medical association in the country opposes laws like Arkansas’s Act 626.

But Levine defended taking a far more conservative approach to treating gender dysphoria, and suggested that transgender people are prone to suicide, depression and other psychological and health problems regardless of whether they access medical gender-affirming treatment. He equated trans-sex hormones for teens with giving a child a train for Christmas. It’s something they very much want, but the happiness it brings will be fleeting, he said.

Levine said he’s treated only about 50 minors with gender dysphoria over his career, but said he’s heard many complaints from parents who said they wished their child had more therapy and that they’d known more about what they were consenting to before agreeing to medical gender-affirming treatments.

Levine lives in Ohio and  acknowledged he does not know what kind of protocols doctors in Arkansas follow when they treat minors with gender dysphoria, but said generally speaking he believes doctors in the United States are far too quick to prescribe medical interventions.

Even with his quirky and old-fashioned takes on gender dysphoria, Levine acknowledged multiple times that he supports gender-affirming medical care in some cases. That care would be banned completely for people under 18 should Arkansas’s Act 626 take effect, making it kind of awkward that Levine appeared Monday as a paid witness for the ban. Doctors should put the brakes on puberty blockers and hormones for young people as Act 626 requires, Levine said, but adolescents and teens already taking gender-affirming hormone treatments should be allowed to continue them to avoid causing psychological harm.

That suggestion is at odds with the law he was there to defend, but Levine suggested the Arkansas attorney general would surely make some sort of legal arrangement to allow this? A spokesperson for Leslie Rutledge declined to answer if that was likely or even possible, legally speaking.

“Due to the ongoing trial, I will refer you back to briefs, expert witness depositions and testimonies,” Amanda Priest said via email. Levine acknowledged doctors who keep treating youth already on hormones might get caught, but he suggested the board would surely decline to dole out any punishments.

Levine tangled a bit under cross examination with ACLU attorney Leslie Cooper, who successfully challenged some of his data. Cooper poked holes in Levine’s assertion that 30% of people in one  study who had gender transitioned eventually returned to their original gender identity. Cooper pointed out that the statistic, actually much smaller than 30%, came from a study of only 41 people, four of whom stopped taking hormones. Whether those four people “de-transitioned” back to their natal sex was not known. On Tuesday, attorneys defending the ban said they plan to call sociology professor Mark Regnerus and plastic surgeon Patrick Lappert. Endocrinologist Paul Hruz is also slated to testify for the state this week. Court will resume at 8 a.m. Tuesday.

*A previous version of this post mistakenly reported that Levine said that those labeled boys and girls at birth now evenly elect for gender transition.