Three-year-old Mia was taking a bath with her younger sister, Isabella, when she turned to her mother and asked, "When is my tail going to fall off?"
Her mother, Rebecca, was taken aback, until she realized the child was talking about a penis. Since she was a toddler, Mia has fought to be a girl and resisted all attempts to interest her in masculine toys and clothes.
"I would rather be dead than be a boy," Mia told her mother when she was 5. The child would later be hospitalized for threatening to kill herself as she struggled through elementary school.
It was only when she was finally able to start transitioning at the Medical University of South Carolina at age 12, and after legally changing her name, that life seemed to make sense for her.
South Carolina legislators sought to stop that last year, when they attached a clause to the annual budget banning MUSC from using state-allocated money to fund "furthering the gender transition" of youth under 16. The directive took effect July 1.
It remains unclear when exactly MUSC ended the services. But the result strands Mia among an estimated 150 patients of that pediatric clinic in downtown Charleston scrambling to find treatment elsewhere, even as they have yet to receive official notice from MUSC.
Other families are pondering leaving the state. MUSC told The Post and Courier it can no longer legally offer the care and is trying to connect families to other health care providers not restricted by the Legislature.
But some Republicans are looking to broaden the ban and make it illegal for all providers in South Carolina to offer gender-transitioning hormone therapy or surgery to anyone under 18.
Mia, now 14, is the name she first chose for herself, but her name was later legally changed to another. The Post and Courier agreed to refer to her as Mia — and to her parents and sister by their first names only — to protect the Charleston family from harassment.
Just how many people are transgender in the United States is not clear, but in South Carolina it could be nearly 3,000 children, according to a Post and Courier analysis.
South Carolina lawmakers like Rep. R.J. May, a co-founder of the hardline conservative Freedom Caucus, say these children have been influenced by "social media, TikTok, Instagram, YouTube" into identifying as a different gender. It was the Freedom Caucus, a subset of House Republicans, that announced the end of MUSC's pediatric services.
"The children right now going through this are the guinea pigs for the new woke sexualization of our children," the Lexington Republican told The Post and Courier.
But having a transgender child was not something Mia's father envisioned for his family.
David is a former chief petty officer in the Navy. He had to enforce Congress' "don't ask, don't tell" policy shift for the military in 1993, which lifted a decades-old ban on gay servicemembers but didn't allow them to be open about it. There were times he had to tell a subordinate to cool it on public displays of affection with a boyfriend and to ask another not to tell him about his sexual orientation unless he was looking to get kicked out of the service.
David saw stigma later as well, working as a contractor at a large factory in North Charleston, where a transgender woman was the butt of rude jokes and derision from male colleagues.
"I started to see my child in the same shoes," David said, fearing the treatment she would receive.
But the unmistakable signs were there early on with Mia.
"We saw at 2 or 3 years old, she wanted to wear girl shoes," David said.
"She wanted everything Izzy had," Rebecca said. "She saw herself like Isabella. They were the same. She couldn’t see why they would be different."
David's efforts to interest her in boy stuff — cars and the like — fell flat. Increasingly, Mia wanted to wear girls' clothes, to grow her hair longer.
It came to a head when she was 7 and David took her to buy shoes at the Skechers Factory Outlet store.
"She wanted the glittery, sparkly shoes, and I was like, 'No, you’re a boy, you’ve got to get regular shoes,'" he said. "We had a meltdown in Skechers. And I’m like, I am not going to have a meltdown over this. Get the shoes you want to get."
In second grade, now wearing girl clothing but still going by her boy's name, Mia made friends with two girls and confided in them, "I wish I was a girl. I want to be a girl." They happily played together the whole week. But the following week, the girls turned on Mia.
"(She) comes home heartbroken because those two friends are now laughing at her," Rebecca said. "Telling her, 'You’re a boy, you can’t be a girl.' And they can’t play with her." She suspects the parents were behind the change in attitude.
At school, Mia then wrote on a piece of paper, "I want to die. Kill me."
Her teacher saw it and became alarmed. The school sent her home and wouldn't let her return until she had a note from a therapist. But Mia said the same thing to a psychiatrist. That's when she was hospitalized at MUSC.
More than half of transgender youth — 53 percent — considered suicide in the past year, and one in five attempted it, according to a 2022 survey by the Trevor Project, a group that advocates for and provides crisis services for LGBTQ youth.
Mia is part of that statistic. She has been hospitalized three times for wanting to kill herself.
"That is our response to people who want to question our parenting, with going forward and letting our child live her truth," Rebecca said. "In all honesty, as a parent, you don’t wish this on your child because you know the hardships that lay ahead of them."
Just before Mia turned 10, the family started the process to legally change her name. As part of that, Mia began seeing Dr. Deborah Bowlby at the Pediatric Endocrinology Clinic at MUSC. They drew blood for labs and X-rayed her wrist to check her maturation, but that was it. That is what normally happens with transgender patients Mia's age.
"(The doctors) are not pushing this because they want to make sure that everything is ready and they are making the right, medically healthy choice for her, too," Rebecca said.
Mia was carefully monitored for more than two years before Bowlby saw enough signs of puberty to start giving her hormone-blocking shots. It wasn't until after she turned 13 that Bowlby agreed to start estrogen therapy. That caution gave Mia's parents some peace of mind, but that is the standard of care recommended for all adolescent patients.
"(Doctors) are checking every single box," Rebecca said. "Someone isn’t going to wake up today and say, 'You know what, I’m a different gender. I’m going to go now and make my doctor’s appointment and they are going to hand me my hormones.' It’s not going to happen. Even with adults, it’s a long process before they will start providing medication."
But that is not what opponents of transgender care claim, said Colleen Condon, president of the Alliance for Full Acceptance in Charleston, which works with transgender families like Mia's.
"No one is getting surgery under 18," she said. "Little kids aren’t getting any kind of drugs. They are getting counseling and planning and that kind of work."
MUSC tried to reassure legislators of that last spring.
In a letter sent amid the budget debate, MUSC said emphatically it does not offer gender reassignment surgery to anyone under 18. Its services for transgender children, offered since 2007, include "access to mental health providers, endocrine medicine providers, social workers and dieticians," Dr. David Zaas, CEO of MUSC Health's Charleston Division, wrote in the letter dated March 29.
But the letter didn't appease Sen. Josh Kimbrell, who authored the ban on MUSC providing gender-transitioning services for minors.
"It doesn't really say what they do, that's the problem," said the Spartanburg Republican, responding to Democrats who accused him of trying to deprive children who may be suicidal of mental health care. "They expressly say what they don't do, but they don't clarify what they do."
Denying that he wanted to withhold lifesaving counseling from any child, he added, "I do, however, think it's inappropriate for the state to fund a clinic whose whole purpose is to encourage a child to make a decision that may be irreversible.”
But puberty blockers that many transgender children receive are reversible, according to the American Academy of Pediatrics, and the hormone therapy some receive is mostly reversible unless, say, a female transitioning to male develops a more prominent Adam's apple or deeper voice.
'Out of her shell'
Most of what Mia received was counseling and therapy. What also made her transition easier was Ashley River Creative Arts Elementary School. Her parents approached the school about making accommodations for Mia.
"We didn’t go in guns blazing," Rebecca said. "We went in looking for a partnership."
As she started fifth grade, before her name was legally changed, the school began calling her Mia. While it couldn't be changed in the system, teachers and staff always referred to her by that name. When Mia got report cards, her old name was scratched out and Mia was written in its place.
A girl who once struggled in school seemed to blossom. Her grades improved, and she was more sociable and engaged.
"She didn’t know how to act as a boy," Rebecca said. "Once she could just be herself, she came out of her shell, and she didn’t have to pretend anymore."
From having to repeat second grade, she got straight As the last quarter of sixth grade and has continued to get As and Bs in middle school. Her classmates mostly accept her as Mia, but there are still incidents, boys who taunt her with her old name. Yet others rush to her side.
"As much as she has had some bullying issues, I am really surprised by the number of people who then stand up for her, too," Rebecca said.
Children aren't Mia's biggest obstacle now.
"It’s now the adults that are trying to make her life harder," Rebecca said. "It’s not the kids. It’s the adults that are being bullies."
That now includes the South Carolina Legislature.
Approval of the budget directive that applies only to MUSC came more than a year after a Democrat in the House filed a bill broadly banning gender-transitioning surgery and hormones for anyone under 18. That bill, co-sponsored by one other Democrat and 28 Republicans, drew the ire of his party leaders and got national attention, but it went nowhere in the Statehouse.
"(Opponents of transitioning) tried to pass gender-affirming bans last year and failed at passing a ban," Condon said. "So instead (they) just used financial pressure with the budget proviso that was included."
Officially, a state budget directive applies only to taxpayer money approved by the Legislature. But it can be virtually impossible for any public agency to prove a specific program and its employees are wholly funded by other sources. And ignoring legislators' budget orders can put future public funding at risk.
This fiscal year, MUSC is getting $188.9 million in state funding, but that is 3.5 percent of its $5.4 billion total budget, according to state budget documents and MUSC officials.
After first being assured MUSC could still continue transgender care for minors without touching state funding, Condon said there was an apparent change of heart later last year.
"They felt like the easier way to handle it was to stop providing this care," she said. So, for the doctors who were prescribing care, "now the doctor’s boss is saying, 'Don’t do it because it is politically unfavorable,'" Condon said.
MUSC also canceled an LGBT health conference it was slated to host later this month, which is now being picked up by Condon's group without any participation from MUSC.
Bowlby did not respond to a request for comment through her work email, but MUSC acknowledged that she went on leave prior to legislators being told in December that the care had stopped.
When pressed for a response on all of these issues, MUSC provided the following statement:
"When MUSC is unable to provide care due to state law or because we do not offer the services that patients and/or families may be seeking, those individuals are referred to outside providers as soon as safely possible and as part of standard medical best practice,” spokeswoman Heather Woolwine said.
MUSC has never specified to parents, legislators or reporters when services stopped.
Mia had a hormone-blocking shot in December and still has a March 31 appointment at the clinic. The only information the family has received about her care ending has been through the news. And it leaves them unmoored.
"When her (hormone-blocking) shot comes up in June, I don’t know yet," David said. "And when she runs out of (estrogen) patches in two or three months, I don’t know yet."
He worries about what will happen if those hormones go away and testosterone then floods in. There is very little evidence to guide them. The archives of the National Library of Medicine has few studies looking at the safety of interrupting hormone therapy for gender-affirming care, with one 2015 review suggesting that "withholding hormone therapy or not providing the proper referrals for care may increase the risk for suicide in this population."
Rep. May, vice chairman of the hardline conservative Freedom Caucus, argues that therapy is actually harmful to those children, who should be receiving mental health services instead.
But that therapy is fully supported by a number of groups, including the American Medical Association, the American Academy of Pediatrics and the American Psychiatric Association.
After seeing several states move to restrict this care for minors, the AMA wrote to the National Governors Association in April 2021 urging its members to oppose the bans.
"We believe it is inappropriate and harmful for any state to legislatively dictate that certain transition-related services are never appropriate and limit the range of options physicians and families may consider when making decisions for pediatric patients,” said the group, which represents over 270,000 physicians. The psychiatric association also strongly opposes states restricting the care.
As for Mia's family, they don't know what to expect the next time they visit the clinic. David said they heard from the LGBT coordinator for MUSC that Mia might be referred to telehealth. There is one statewide provider that does that and also practices in the Columbia area; there is another that is in the Greenville area, Condon said. A clinic just across the state line in Augusta could also be an option.
Either way, families are scrambling now to find one of the few other providers in the state and get on their calendars, Condon said.
Or they are are thinking about leaving. Of the transgender families Mia's family has gotten to know over the years, most have left, many to more welcoming states like Massachusetts.
"We’ve had to contemplate and discuss, do we follow suit of the families we’ve seen move?" Rebecca said. It would be hard for them because she has joint custody of Isabella, and her father lives in Charleston.
"We can't, really," David said.
Condon said that might ultimately be the intent of banning transgender care for children.
"I’ve known multiple families of trans kids leaving because they feel like they can’t protect their children in the health care field, in the education field," she said. "I’m not sure that news is in any way disappointing to the Freedom Caucus members. I think they’d rather see people that they don’t see as their constituents leave the state."
May denies that is the intent of banning the care.
"What I want these children to do is get the therapy they need to work through their gender dysphoria,” he said, adding he is praying for Mia's family.
"I feel for this family," May said. "I wish them nothing but a strong family nucleus and support that their child gets the help they deserve" but not hormone therapy or surgery.
Sen. Marlon Kimpson said he hopes bills already introduced in the Legislature to ban gender-affirming care for youth never reach the Senate floor.
"I can understand both sides of the argument, particularly as it relates to a minor having what could be a life-altering permanent situation," said the Charleston Democrat, who objected to the ban during floor debate last year.
"But in principle, I’m against the Legislature having influence on an area that is traditionally reserved to the doctor and patient and, in this case, a minor’s family," he continued. "I don’t think we should dictate to the medical community what is in their province to decide."
'More than just a label'
Isabella is fighting back in her own way, starting a petition on Change.org to "Stop South Carolina from Banning Trans Affirming Health Care to Minors," which had gathered 94 signatures toward its goal of 100 as of March 6.
"(T)rans kids are still humans, and should have basic human rights just like everyone else," it reads.
Mia, who is still quiet and shy, practices the flute, the same instrument her mother played, and would prefer to be left out of all of this.
"I didn't choose to be transgender, but it's a part of who I am," she said. "I am so much more than just a label. I am an artist, a musician, a student, a daughter and a sister. Decisions about my health care should be limited to myself, my parents and my doctor."
It is not just her and the patients at the MUSC clinic who have been targeted. There were over 100 bills filed in 27 state legislatures this year seeking to ban transgender care for minors, with bans passing in Mississippi, South Dakota, Utah and Tennessee, according to a Post and Courier review of legislation compiled by the American Civil Liberties Union. They join bans on transgender care already passed in Alabama, Arkansas and Florida.
In South Carolina, a statewide ban is a priority of the Freedom Caucus, which formed nearly a year ago as a subset of House Republicans. The sponsors of the House bill include all 20 members of the hard-line conservative GOP group that's publicly feuding with the larger House GOP Caucus. That alone could hurt its chances.
Regardless, the ban for MUSC is expected to continue. While clauses in the state budget directing how money must — or, as in this case, can't — be spent are technically one-year temporary laws, they tend to get rolled over from one year to the next indefinitely.
The budget process for 2023-24 is in the early stages. But the version advanced to the House floor for debate this week includes the same ban for MUSC.
For their part, Mia's parents are baffled by the focus on this issue instead of what they would consider things that really matter, like improving roads or helping families put food on the table.
"None of this is changing anyone else’s life for the better," Rebecca said. "It is just going to make lives harder."