While individual states are battling over transgender healthcare, some patients and providers on the ground have been left with few options.
Since 2021, at least 24 states have enacted bans on medication and/or surgical care for transgender youth, and six of those states—North Dakota, Idaho, Oklahoma, Alabama, Florida, and South Carolina—have criminalized care like hormones, surgeries, and puberty blockers for transgender youth, according to the Movement Advancement Project, a think tank that researches laws affecting the LGBTQ+ community.
Nearly 39%, or about 118,300, transgender children live in states that have passed laws against gender-affirming care, according to the health policy research firm KFF.
“Trans healthcare has never been more important,” Liana Guzmán, CEO of LGBTQ+ digital primary care company Folx Health, told Healthcare Brew.
Transgender care ranges from using a patient’s correct name and pronouns to prescribing puberty blockers and hormones to performing gender-affirming surgery. A 2022 large-scale study from the Trevor Project, a suicide-prevention nonprofit for LGBTQ+ youth, showed that there is a link between gender-affirming hormone therapy and lower rates of depression and suicidality in adolescents and young adults aged 13 to 24.
“[Gender-affirming care] is medically necessary,” Terrance Weeden, a pediatrician in Washington, DC, told Healthcare Brew. “It’s a careful, detailed process with multiple different healthcare professionals providing input.”
Clinical consequences
According to the public policy research organization Center for American Progress, which advocates for transgender healthcare, 28% of trans patients reported avoiding or postponing care for “fear of experiencing discrimination” by medical staff.
Dallas Ducar, former president and CEO of Massachusetts-based nonprofit clinic Transhealth, told Healthcare Brew that “we are at a momentous time in history,” because “over the couple of years, we’ve seen many states—on a statewide basis—work to try to ban the access to life-saving, gender-affirming healthcare.”
“Not in recent history have we seen one state’s felony be another state’s pathway to liberation,” she added.
According to University of California, Los Angeles School of Law’s think tank the Williams Institute, most states with bans now require licensing boards to take disciplinary action against physicians who provide banned transgender healthcare services—including revoking a provider’s medical license—and private citizens can bring lawsuits against doctors for providing gender-affirming care. In more than five states, felony charges and jail time are on the table.
In addition to restrictions on gender-affirming care for minors, seven states limit access for adults, per KFF data. Ohio also attempted to ban the care for adults but pulled back on the proposal in February.
Zooming in
In states with bans, keeping facilities that offer transgender healthcare open has been a challenge.
Joseph Knoll, founder and CEO of Spektrum Health and advanced practice nurse, told Healthcare Brew that it has felt like “just chaos” at his Orlando-based LGBTQ+ primary care facility since the state restrictions went into effect.
The Florida Legislature’s ban on gender-affirming care for youth that went into effect in May 2023 was overturned this June after a group of parents challenged the law. But the state appealed, and a federal judge ruled in August that the ban would stay in place until a final decision is made.
Navigate the healthcare industry
Healthcare Brew covers pharmaceutical developments, health startups, the latest tech, and how it impacts hospitals and providers to keep administrators and providers informed.
Amid the uncertainty, Spektrum told patients to schedule an appointment to have their prescriptions refilled for gender-affirming care. Spektrum also provides other primary care services like diagnoses and treatments for common conditions including diabetes and HIV, as well as weight management and mental health care.
Knoll said that, of the clinic’s 3,000 patients, “2,600 and some of our patients didn’t miss a single dose during those 13 months.”
When the law was in effect, Spektrum also had to recruit a doctor to work at the facility to prescribe gender-affirming medications, as required by the new legislation. The process took 13 months, cost the clinic at least $25,000, and was very challenging, Knoll said, as many physicians were hesitant to accept the job due to the shaky landscape and concerns about legal backlash.
“There was more loss than just trans people accessing their care. It put healthcare providers like me in very ethically and morally compromising positions, where now I have a law that tells me what it is and isn’t OK,” Knoll said.
About 20% of transgender and nonbinary youth attempted suicide in 2022, according to the Trevor Project. “I have to watch people decline and deteriorate and be at risk for injury and self-harm,” he said.
Spektrum continued to provide primary care services to its patients. In this way, Knoll said he wanted to have a safe space for queer people and also ensure that patients were up to date on other medical needs.
“We realized that keeping our doors open was critical,” Knoll said. “Even if we can’t get prescriptions, human touch and interaction can be medicine, too. Having people come in for their appointments and addressing them by their chosen name and using the correct pronouns, normalizing their needs, letting them know what’s happening is not OK. That became the medicine that we had.”
What’s next?
As of August 27, 17 states are facing lawsuits over trans care bans, according to KFF. Critics, including the American Civil Liberties Union, have claimed the policies violate the 14th Amendment, which provides all citizens equal protection under the law.
One case in Tennessee is going up to the Supreme Court to decide if the state’s ban on trans medical care for minors is legal. That case is expected to be heard during the court’s next term, which begins in October.
Meanwhile, New Hampshire’s ban is set to go into effect in January 2025.
“We are at a real critical juncture in our nation’s history where we’re seeing the politicization of healthcare,” Ducar said. “At the end of the day, this is about freedom to be who one is, the liberty to make one’s own choices about one’s own life, and the ability to pursue happiness.”