RI Dems Try to “Shield” Ivy League Doctors

Sanctuary state bill highlights class predation at the heart of gender medicine

The tiny state of Rhode Island is home to two of the world’s most notorious gender doctors, Michelle Forcier and Jason Rafferty. The state senate just approved a bill that would make these cold shores a friendlier place for them to do business, according to its sponsors.

At least 10 blue states have recently passed “sanctuary state” laws that purport to shield gender doctors, trans-identified kids, and pro-medicalization parents within their borders from lawsuits or other unpleasantness that might originate in other states. (I say “purport” because the laws’ sponsors tend to overpromise; many provisions either are vacuous or conflict with other laws.) RI’s bill falls into this category. It focuses on the concerns of gender doctors, with some additional pieces that would purport to block investigators’ access to medical records and protect people who aid someone in seeking gender medicine. 

One thing missing compared to last year’s sanctuary state bills: provisions purporting to seize jurisdiction over kids who show up in RI seeking gender medicine. I suspect the national movement finally faced the fact that interstate child custody is too thorny for them to effectively deal with. (Edit 10/4/24: here’s my post on Minnesota’s version, which was passed in 2023 and addresses child custody.) In RI’s bill, we may be witnessing sanctuary state 2.0.

In this post I’ll break down RI’s sanctuary state bill and place it in its clammy context. I'll also explain the two big detransitioner lawsuits that are pending against Forcier and Rafferty. One of them also names the American Academy of Pediatrics.

Welcome to my trans-addled homestate.

What Is an Island?

This newsletter has international readers, improbably enough, so I’ll start basic.

Rhode Island is the smallest state in the US by land mass, wedged up in southern New England. It’s not an island, but it contains a lot of islands. Everyone there lives near the water – a bay and an ocean – but most don’t identify as beach people because they think 15-minute drives are too long. Boston is an hour or so to the north.

Rhode Islanders like to make fun of themselves for supporting corrupt politicians and eating pizza without cheese. They’re so doggedly self-deprecating that I thought it was one of the poorer states in the US and was surprised, researching this post, to find it’s actually OK. But it is a chill normal state surrounded by snooty neighbors: Massachusetts, Connecticut, and (if you’re sailing) New York. The contrast itself sets an underdog tone.

The state contains a few topsy-turvy pockets of ultra-wealth. One is a museum zone in Newport where descendants of Gilded Age villains live in the American version of medieval castles. 

A more virile locus of power: Brown University, a beacon for queers whose math teachers admire their leadership skills and Asian-Americans who support affirmative action but disguised their race on their application. I kid, but Brown is beloved (among people whose other options were Georgetown and Tufts). It’s the cool ivy. The kids at my high school who despised Rhode Island for being “hick” were the ones most wrecked by their Brown rejections. They’d filled out the application by hand because the admissions committee preferred it that way. Brown is also the twee ivy.

But Brown isn’t some tiny liberal arts college. It’s a big thrumming university with engineering and med schools. It influences the whole state; there are few powerful institutions to counter it since the mafia fell apart. Sometimes that’s good. When I was three, Brown-affiliated doctors saved my life with an innovative procedure. The dilapidated hospital in which they treated me resembled a haunted parking garage.

In the 2020 presidential election, only 38% of RI voters picked the republican, Donald Trump. You could’ve predicted that based on demographics alone: the only religious people are cafeteria Catholics and most of the population lives in or near Providence, a diverse city. 

As a teenager I found the dem-by-default posture stultifying. To scandalize the grown ups, I only applied to colleges in the South. But they were all supportive of my desire to get 500 miles away because again, Rhode Islanders are not excessively prideful about their homeland.

Last year a trans-identified man took over the RI Democratic Women’s Caucus. Eat your heart out, Massachusetts.

Birthplace of the Affirmative Revolution

Jason Rafferty

Brown Med employs Michelle Forcier and Jason Rafferty, two psychiatrist-pediatricians who are credited with pioneering the “affirmative care model” of treating trans-identified kids in the 2010s. This model involves, basically, giving kids whatever intervention they want when they want it. (The word “affirmation” was pushed by child gender doctors as early as 2008.)

Forcier famously asked Matt Walsh, “does a chicken cry?” She told NBC News in 2015:

“The big place for gender is our brain, our heart, and our soul. Identity. Who we are. Which isn’t parts. It’s in here.”

Forcier’s mentee, Rafferty, authored the 2018 American Academy of Pediatrics’ policy statement in favor of transing kids (the link goes to the debunking). Rafferty is relentlessly cheery and glib, and he never strays from his thesis that affirmation is good. “People are really resonating with this idea of affirmation!”

Jennifer Block in the Boston Globe last year:

“Rafferty told me patients who live with harms or regrets do not signal a failure of the affirmative care model. If a child or patient doesn’t like the effects of an intervention, or begins to feel different in their identity, then the provider continues to affirm by discontinuing treatment. ‘They’re not treatment failures if that’s what’s affirming,’ he said.”

Affirmation isn’t a means to the end of mental health. Affirmation is the end.

Michelle Forcier gives new meaning to the term “blue-haired old lady”

Forcier and Rafferty practice in the local community, where parents are likely to see their Brown affiliations and think of someone they know whose life was saved by brilliant Brown doctors.

In October 2023, two detransitioners filed blockbuster malpractice lawsuits in RI state court against Forcier, Rafferty, and others. One of the suits also named the American Academy of Pediatrics. 

The plaintiffs are represented by Campbell Miller Payne, the Dallas-based firm that launched last year to bring all the gender medicine lawsuits that should have been brought for the last 50 years.

Isabel Ayala’s lawsuit – the one that names the AAP – describes the defendants as “a group of ideologues set on promoting their own agenda and furthering a broader conspiracy at her expense.” It details their machinations:

“These individuals saw an opportunity to pioneer new guidance on an emerging field in pediatric medicine—the treatment of the rapidly increasing number of children and adolescents presenting as transgender and gender diverse—that would enshrine as authoritative their ideological beliefs. But finding no evidentiary support for their radical positions, they nonetheless prepared and authored a ‘policy statement’ reviewed, approved, and published by Defendant AAP, proposing an entirely new model of treatment, which not only misrepresented or misleadingly presented its purported evidentiary support but was also rife with outright fraudulent representations.”

The lawsuit describes how Forcier and Rafferty reaped money and prestige from their leadership in spreading the “affirmative model of care,” even as its fraudulence was exposed. (Edit 10/4/2024: In September 2024, 22 states announced they were investigating the AAP’s role in developing and promoting the policy statement.)

When Rafferty met Ayala, she was a troubled 14-year old survivor of sexual abuse who’d just moved to RI with her father; her mother lived in Florida. She had a family history of mental illness.

Ayala’s suit names four other gender doctors in addition to Forcier and Rafferty, at least two of whom were affiliated with Brown.

The other RI plaintiff is Layton Ulery. Her suit names Thundermist Health Clinic which, according to my RI social worker informant, serves poor people. Ulery had just escaped a vicious cult which tried to cure her of her homosexuality, among other horrors, and was struggling with multiple personality disorder when she met Rafferty and Forcier. The lawsuit describes her situation at the time as “perpetually on the brink of homelessness and in a constant state of food insecurity.”

Ulery needed a range of services from Thundermist, including “psychological support.” But:

“once she informed Dr. Rafferty of her wish to discontinue the [testosterone] treatments, support from the Thundermist team dried up. For example, during the time Layton was active in pursuing transgender medicalization, Thundermist provided transportation for her to and from her appointments. But after she ended the transgender-affirming treatments with Rafferty, transportation to her other Thundermist appointments was now suddenly unavailable to her.”

Ulery’s case was transferred to federal court in RI at the defendants’ request. Otherwise there have been no major rulings yet in the RI detransitioner suits.

Thundermist in West Warwick, RI

Healthcare Provider Shield Act

This year RI dem legislators introduced the Healthcare Provider Shield Act in both houses. The Senate approved it today and now it awaits consideration in the Assembly, where Democrats hold 65 of the 75 seats. (Edit 10/4/24: The bill became law in June 2024.)

The Shield Act sponsors’ description:

“Creates a protective legal shield for healthcare providers, precluding any civil/criminal action by other states/persons against healthcare providers involving persons seeking access to transgender and reproductive healthcare services provided in RI.”

The Providence Journal summed up the debate. Critics include a lesbian and a sex abuse survivor both concerned about young gender patients. The bill’s senate sponsor, Dawn Euer, pointed out that Connecticut and Massachusetts had already passed similar “common sense” laws.

Sanctuary state laws are weird. Reading them I have thoughts like, This provision is either totally empty or will start a civil war. They mostly tinker with procedural rules, which makes them hard to analyze. I assume that’s why they haven’t received the attention they deserve.

Here’s my breakdown of RI’s Shield Act. 

Trans Rights Are Women’s Rights

The bill force-teams gender medicine with abortion even though the procedures are different. Abortion is safe, never pursued based on a misdiagnosis, doesn’t create a lifelong revenue stream for the provider, and gives patients exactly what they ask for.

No Hostility Allowed

The bill aims to protect doctors from “hostile litigation,” a term it uses to refer to lawsuits brought against RI abortion/gender doctors in another state, under that state’s laws. This made me laugh because all litigation is hostile if you want to act melodramatic about it. 

I’m not sure how many lawsuits against doctors the Shield Act would actually apply to. Med mal actions typically must be brought in the state where the care was administered. For another state to have jurisdiction, the doctors would need to have done something in that state like market themselves to the plaintiff. Are RI gender doctors advertising for business in Alabama? Why are they fighting for that right?

I think the Shield Act is more likely to impact doctors as they are hit with subpoenas related to out-of-state litigation or child custody disputes. More on that in a minute.

Gender Doctors Are Rubber and You’re Glue

Anyone named in hostile litigation or subpoenaed in connection with it would be deemed an “aggrieved person” who may sue the plaintiff/subpoena-issuer in RI.

This is unusual. One similar area of law: SLAPP (strategic litigation against public participation). In a SLAPP lawsuit, the plaintiff sues someone for defamation but doesn’t have a valid legal claim; their goal is to bully the defendant into shutting up because they don’t want to pay a lawyer to fight the suit. Many states allow the defendant to counter-sue under an “anti-SLAPP” statute. The state does this to protect free speech. 

By contrast, RI’s Shield Act aims to protect abortion/gender doctors’ commercial interest in treating out-of-state patients.

Deferring to a Reputable Authority

What kind of healthcare is protected here, exactly? Emphasis added:

"’Transgender healthcare services’ means all … care … relating to the treatment of gender dysphoria and gender incongruence as provided in accordance with the accepted standard of care as defined by major medical professional organizations and agencies with expertise in the relevant field including the World Professional Association for Transgender Healthcare Standards of Care for the Health of Transgender and Gender Diverse People, 8th edition, or its successor in function.”

“Standard of care” is a legal term of art from the world of malpractice law. It’s defined by courts, or should be. Codifying it as whatever “major medical professional organizations” want is a giveaway to the healthcare industry.

But the Shield Act wouldn’t affect the standard of care in malpractice law; confusingly, it would just create a new concept with the name “standard of care” for courts to consider when deciding whether the provisions of the Shield Act apply to a situation.

It’s chancy to enshrine WPATH into law as a medical authority. I mean sure, SOC8 is great, all upstanding swamp yankees believe in validating eunuchs, but what if SOC9 does something radical like remove age floors for vaginoplasty?

(That was a joke, SOC8 already did that.)

Edit 10/4/24: WPATH’s internal emails were revealed in June 2024. They showed that SOC8 was drafted based on legal and political concerns, thus undermining WPATH’s claim to be a medical authority.

Price Controls for Gender Doctors

The Shield Act would ban insurance companies from “charging higher rates for a malpractice policy” or “imposing any … rate increases” to RI doctors based on their abortion/gender practices. 

Higher rates than what? The year before? Other specialties? Does that mean insurers have to offer gender doctors rates that are lower than every other doctor’s?

This protection applies “as long as the care provided by the applicant or insured was consistent with the applicable professional standard of care[.]” Say a doctor lost a malpractice lawsuit and the judge found she breached the standard of care. The insurance company would want to raise her rates. It couldn’t necessarily do so because, recall, the Shield Law has its own special definition of “standard of care” based on WPATH's say-so.

RI gender doctors just attracted two megawatt malpractice lawsuits because they are nationwide leaders in transitioning kids. The state’s population is only about 0.3% of the USA. If insurance companies can’t charge more for a product that costs them more, will they stop covering RI doctors altogether? Or will they charge the other RI doctors more to make up for the cost of Rafferty and Forcier’s iatro-joyrides? 

No Judgment

You might hear that sanctuary state laws block the enforcement of out-of-state judgments, meaning a plaintiff who successfully sued a gender doctor elsewhere couldn’t put a lien on their house in the sanctuary state.

The Shield Act’s text is narrower that, only nixing certain types of judgments (emphasis added):

“In any action filed to enforce a foreign [i.e., out of state] judgment issued in connection with hostile litigation, a court of this state shall not give any force or effect to any judgment issued without jurisdiction or due process[.]”

RI would actually let the victorious plaintiff put a lien on the gender doctor’s house, so long as the judgment was won properly there. I imagine that language was added to color within the lines of Article IV of the US Constitution, which states:

“Full faith and credit shall be given in each state to the public acts, records, and judicial proceedings of every other state.”

The Shield Act would let “aggrieved persons” sue people who tried to enforce judgments from hostile litigation, even if the judgment were properly obtained in the other state. This seems to violate Article IV.

Subpoena Games

The Shield Act aims to block courts, state agencies, and private businesses from cooperating with out-of-state investigations and discovery related to abortion/gender medicine.

This could impact interstate child custody disputes. For example, imagine a pro-medicalization parent is with the kid in RI, and the anti-medicalization parent is in another state; or another state’s child welfare agency is involved in a kid’s life, and then a parent takes the kid to RI. The Shield Act would interfere with any efforts from the out-of-state parent/agency to find out whether the kid was being transitioned. (It’s limited to cases where civil or criminal liability could be imposed in another state, but I think that could include child custody cases because, for example, family courts can issue contempt orders.)

Here are the nuts and bolts.

Serving someone with a subpoena in a different state can be tricky because they’re not under the jurisdiction of the court you’re litigating in. Like most states, RI has smoothed that process out by adopting the Uniform Interstate Depositions and Discovery Act (UIDDA). It lays out the steps that out-of-state litigants need to follow to have their subpoenas “domesticated” in RI. If you check all the boxes, the process should be easy:

“When a party submits a foreign [out-of-state] subpoena to a clerk of court in this state, the clerk, in accordance with that court’s procedure, shall promptly issue a subpoena for service upon the person to which the foreign subpoena is directed.”

The Shield Act would ban judges and clerks from issuing subpoenas “in connection with hostile litigation” – setting up a conflict with RI’s UIDDA. (Apparently it would not violate the Full Faith and Credit clause of the US Constitution.) It would also add a whole new category of labor for courts. They’d need to create a process for reviewing all out-of-state subpoenas for possible links to “hostile litigation,” and then someone would have to make a decision about whether the Shield Act applied.

If a subpoena found its way to a “business entity that is incorporated, or has its principal place of business” in RI, the Shield Act would bar the business from complying. The business would have to move to quash the subpoena, meaning, petition a court to let it off the hook – something that is often more of a hassle than complying. 

Would this even benefit gender doctors in the end? Instead of planning to duke out any subpoenas under this sketchy law – where the outcome of any conflict is unclear – they could just decline to transition any kids with a parent or open child welfare case in another state.

Both Ayala and Ulery were new to RI when they first met Rafferty. It could be a coincidence. But if gender doctors whine about their need to transition out-of-staters, legislators should ask them exactly how many of their patients are girls separated from their mothers by hundreds of miles.

Trickle-Down Healthcare

I suspect the Shield Act is mostly a placebo for RI gender doctors and activists. To the extent they have anything to worry about from red states, this bill won’t solve the problem. But their hearts will be warmed by elected officials’ votes and bluster for their cause.

Sidenote: I wonder whether red state legislators will pass laws that shield its favored industries from blue state attorney general investigations related to consumer protection, wage theft, and so on.

Supporters of the Shield Act spin it as pro-patient. Here’s Heather A. Smith, president of the RI Medical Society:

“We need the Health Care Provider Shield Act to ensure Rhode Island remains a state where clinicians want to practice, and so that physicians can continue to provide our patients with quality, compassionate, and essential care when they need it.”

Pass laws that make us feel good or we’re moving to Massachusetts like everyone else!

When legislators really want to protect patients, they don’t do it by setting a rock-bottom standard of care and mucking with the malpractice insurance market. Rather, they increase accountability and fund independent research.

Because legislators don’t fund independent research into gender medicine, we don’t know how many gender patients are poor. Whistleblowers talk about kids from troubled homes; Hannah Barnes reports that foster kids are “hugely over-represented” among gender patients in England and Wales; historical records hint that teen prostitutes were a major cohort of transsexuals from the beginning; the ACLU puts charming parents on the witness stand and no one wants to point out how unsophisticated they sound.

The victims of gender medicine are still coming into focus. But we know exactly who the perpetrators are. They’re the biggest creeps in Rhode Island.

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Unyielding Bicyclist