Texas Attorney General Ken Paxton has issued an opinion declaring that gender-affirming health care for transgender youth, including hormone therapy and puberty blockers, is a form of “child abuse.”

Paxton issued his opinion in response to an inquiry from State Rep. Matt Krause (R-Fort Worth), a former rival for Paxton’s current post who has since dropped out of the AG race and is running to be Tarrant County District Attorney.

Krause, a prominent anti-LGBTQ politician, has previously pushed for “right of refusal” bills that would allow people, government officials, and businesses to refuse to serve LGBTQ people or recognize same-sex marriages based on their personal religiously-based opposition to marriage equality.

He has also used his position as chair of the House Committee on General Investigating to push for censorship of at least 850 different books with content related to human sexuality, STDs or HIV/AIDS, sexually explicit images, graphic presentations of sexual behavior, or any “material that might make students feel discomfort, guilt, anguish, or any other form of psychological distress because of their race or sex or convey that a student, by virtue of their race or sex, is inherently racist, sexist, or oppressive, whether consciously or unconsciously.”

As part of his inquiry, Krause demanded that Paxton opine on which specific surgical procedures that are employed to assist in a gender transition would constitute “abuse” if performed on minors.

Krause also asked Paxton to determine whether administering drugs to suppress the onset of puberty, or “supraphysiologic doses” of testosterone and estrogen, should also be considered a form of abuse.

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On Monday, Paxton issued a response to Krause’s inquiry, stating that all the forms of surgical and hormonal interventions referenced in the inquiry constitute “abuse,” which is defined broadly under Texas law, and could be used to define instances where medical procedures might cause “sterilization.”

According to Paxton, the Constitution protects a fundamental right to procreation, and because minors are “legally incompetent to consent” to transition-related procedures, treatments that cause sterilization infringe upon that right.

“Each of the ‘sex change’ procedures and treatments enumerated above, when performed on children, can legally constitute child abuse under several provisions of chapter 261 of the Texas Family Code,” Paxton wrote. “When considering questions of child abuse, a court would likely consider the fundamental right to procreation, issues of physical and emotional harm associated with these procedures and treatments, consent laws in Texas and throughout the country, and existing child abuse standards.”

In his opinion, he compared gender-affirming health care treatments to the ravages of the opioid epidemic that has been triggered by the prescribing and marketing of high-grade pain relievers by doctors and pharmaceutical companies, writing: “There is always the potential for novel medical determinations to promote purported remedies that may not improve patient outcomes and can even result in tragic harms. The same potential for harm exists for minors who have engaged in the type of procedures or treatments above.”

It remains unclear what the effect of Paxton’s opinion will mean for transgender children, since attorney general opinions do not have the force of law, reports The Dallas Morning News.

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However, if Texas were to push for a bill barring all minors from receiving gender-affirming medical care, like the one pushed for by Gov. Abbott’s primary opponent, former State Sen. Don Huffines (R-Dallas), it is likely that doctors would be intimidated from prescribing any form of treatment for fear of losing their license, and that parents might avoid affirming their child’s gender identity for fear of losing custody if charged with “child abuse” under a hypothetical statute defining transition-related care as such.

If such a bill were to pass, transgender minors would, in essence, be told to suffer in silence, struggling with their feelings of gender dysphoria and feelings of depression, anxiety, or low self-worth until they reach their 18th birthday and can begin pursuing medical interventions independently of their parents.

Advocates note that for children who have not reached puberty, mental health care is the primary form of treatment for gender dysphoria. According to best practices set out by the World Professional Association for Transgender Health (WPATH), hormone therapy should only be prescribed for youth who have already experienced the onset of puberty and have undergone mental health evaluations.

Under those “best practices” guidelines, surgery is not recommended for minors at all, and adults seeking to undergo procedures should have lived continuously for at least a year in the gender consistent with their gender identity. Additionally, most major medical groups recommend providing age-appropriate, individualized care for trans youth suffering from gender dysphoria, rather than imposing one-size-fits-all interventions on people who may not need it.

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WPATH panned Paxton’s opinion as uninformed and propagandistic.

“Targeting trans youth, their parents, and their health care providers for political gain is unconscionable,” the organization said in a statement. “We strongly denounce this alarmist and misguided opinion which could obstruct access to medically necessary care. It is yet another example of the profound misunderstanding of the conditions under which transgender people live, and a profound lack of compassion for the need for responsible medical care that helps trans people, including trans youth, to thrive and contribute to society.”

Last year, Texas Republicans tried and failed to pass a bill banning gender-affirming treatments for trans youth. Similar bills have previously passed in Tennessee and Arkansas. After a federal judge blocked the latter law from going into effect, Paxton was one of several dozen conservative attorneys general signing on to an amicus brief defending the law and calling trans health care a form of “experimentation” on children.

Last August, after receiving pressure from Gov. Abbott, the Texas Department of Family and Protective Services changed its definition of “abuse” to include gender confirmation surgery for minors, and promised to investigate any allegations that the practice was occurring.

In response, the Texas Pediatric Society sent a letter, dated Aug. 16, to the agency urging it to base its decisions on science and outlining which specific treatments or interventions are prescribed and when they are generally recommended.

“Medical care for transgender children and adolescents is evidence-based and has proven effectiveness,” Dr. Seth Kaplan, the Society’s then-president wrote to DFPS Commissioner Jaime Masters on behalf of the organizations’ 4,600 members. “The decision of whether and when to initiate gender-affirmative treatment is personal and involves careful consideration of risks, benefits, and other factors unique to each patient and family. These are medical decisions reached in consultation between the patients and their parents. The process involves repeated psychological and medical evaluation, with the participation and consent of a child’s or adolescent’s parents.

“As physicians, we must be able to practice medicine that is informed by our years of medical education, training, experience, and available evidence, freely and without threat of punishment,” Kaplan continued. “Providing patient care that helps rather than harms is our duty according to the oaths we took as doctors. Gender-affirming care is part of the comprehensive primary care we provide to our patients and should not be criminalized or stigmatized.”

Paxton’s opinion coincides with ongoing attempts to restrict LGBTQ rights, particularly protections for transgender students in schools, as well as the aforementioned push by Krause for censorship of classroom materials — which critics say will simply be broadly interpreted by reactionary school boards, spineless school administrators, and hypersensitive parents to justify banning any works with an LGBTQ character or LGBTQ content, even if the character or “offending” content is irrelevant to the central plot of a book.

The opinion also conveniently drops as Paxton — no friend to the LGBTQ community — faces a competitive primary challenge from three other prominent Republicans, including Texas Land Commissioner George P. Bush, the grandson and nephew of two former U.S. presidents. Due to the depth of the field, it is unlikely Paxton can emerge as the frontrunner without avoiding a runoff election, which critics say incentivizes him to do anything he can to appeal to Republican base voters.

Ricardo Martinez, the CEO of Equality Texas, criticized Paxton’s analysis, saying that the statewide LGBTQ rights group believes children should have a right to access any gender-affirming treatments that have been carefully prescribed by medical experts based on an individual patient’s needs. 

“We urge all Texans to be skeptical about campaign stunts disguised as legal opinions from a corrupt politician who has built their career spreading disinformation about marginalized communities and who has no expertise in healthcare,” Martinez said in a statement. “Since the beginning of the 2021 legislative session, anti-LGBTQ+ politicians, including the governor, lieutenant governor and attorney general have sought to lay the groundwork to turn Texans against their LGBTQ+ neighbors through an onslaught of harmful legislation, inflammatory rhetoric and discredited legal opinions. They have found it politically advantageous to spread lies about and villainize LGBTQ+ people, especially transgender people, grossly mischaracterizing our lives to paint us as scary caricatures that need to be feared, all in service of securing their re-elections. 

“Disinformation, being spread about transgender people and their healthcare, highlights, exaggerates and imagines a non-existent problem as an urgent moral emergency that must be tackled right now — days before the primary election. It’s predictable and sad that during a crowded primary, politicians will further sow civil discord by amplifying lies about trans people to score political points. Misconstruing the law and amplifying junk science to attack innocent children and their parents is cruel, beneath contempt, and could have a devastating effect on transgender youth and their families.”