- A growing number of states in the U.S. are proposing or enacting legislation to restrict gender-affirming care for minors.
- In some places, healthcare professionals are dropping coverage for gender-affirming care for kids, even though it’s legal.
- Access to gender-affirming care is crucial to the well-being of transgender and gender-diverse youth. In many cases, it can even be lifesaving.
Transgender and gender-diverse youth face an uphill battle in many parts of the United States.
Their identities are often points of political debate and discussion, which can impact the mental and physical health of children and adolescents during some of the most vulnerable periods of their lives.
This has starkly been the case as efforts to restrict and prohibit access to gender-affirming care increase around the country.
LGBTQ advocacy nonprofit Movement Advancement Project outlines 22 states where legislation has either been proposed or enacted in recent years to ban best-practice medical care for trans youth.
Some of these restrictions are in flux and have been challenged legally. It leaves trans and gender-expansive young people, their families and guardians, and doctors on edge, unsure of the fate of their access to this necessary healthcare.
In some states where gender-affirming care is legal or where bans have been passed, those already undergoing hormone therapy, for example, are allowed to continue to receive gender-affirming care.
Still, access and support for pediatric gender-affirming care around the U.S. remains complicated and fraught.
In places where gender-affirming care is legal, some doctors are dropping coverage for this form of care over liability provisions included in anti-gender-affirming care policies and bills.
Gender-affirming care is an umbrella term that can refer to a broad range of medical, social, and legal interventions and supports that allow a person to feel safe, happy, and secure in their gender.
The Associated Press recently reported that in states like North Dakota and Missouri, where young people are legally allowed to receive gender-affirming care, some healthcare providers are dropping coverage.
In Missouri, the AP reports that a provision in that state’s law restricting access to gender-affirming care enables a patient to potentially sue for injury from any treatment they receive until the age of 36. This could extend to later ages if the reported harm exceeds the 36-year marker.
The provider would assume the burden of proving the patient’s harm didn’t occur from puberty blockers, for instance, with minimum damages awarded at $500,000.
Understandably, this kind of provision puts providers and the larger health systems that employ them in a difficult position.
“Among the 22 states that have enacted polices restricting or prohibiting minor access to gender affirming care, 5 state laws include felony penalties for providers offering these services and 18 have civil or professional penalties. These provisions will undoubtedly limit provider willingness to offer this medically necessary care. It could also have a chilling effect on providers outside these jurisdictions,” Lindsey Dawson, MPP, associate director of HIV Policy and director of LGBTQ Health Policy at KFF, told Healthline.
“Providers who have historically offered minors gender affirming care in these states are forced to decide between offering what they know to be, and what the medical literature supports, is in the best interest of their patients and is medically necessary or facing potential sanctions, including in some states, loss of license or a felony charge,” she added.
For Kellan Baker, PhD, MPH, an affiliate faculty member at the George Washington University Milken Institute School of Public Health and the Executive Director of the Whitman-Walker Institute, the purpose of these liability provisions are designed to “intimidate and terrify providers” and “drive them out of the space” of offering this care to trans and nonbinary people.
Baker told Healthline that laws that extend the timing of potential malpractice suits to “15, 20, plus 20 years” after administering the care is damaging to the mission of making gender-affirming care accessible to the young people who need it.
In many instances, access to gender-affirming care can be a matter of life and death.
Past research has shown the positive impacts of access to gender-affirming care for minors. Access to gender-affirming care inevitably improves mental health outcomes.
Jonah DeChants, PhD, a senior research scientist at The Trevor Project, a nonprofit supporting LGBTQ young people, emphasized the importance of gender-affirming care.
De Chants cited a 2021 peer-reviewed study by Trevor Project researchers showing that gender-affirming hormone therapy was associated with significantly lower rates of:
“This lifesaving care can help trans and nonbinary young people live happier, healthier lives, and lawmakers should be actively working to increase access, not strip it away from kids who need it the most,” he told Healthline.
Of course, research has also detailed the inverse — of how damaging it can be when gender-affirming care remains out of reach.
Baker explained that in some cases, these laws can expand malpractice lawsuits, with parents being able to sue based on their child’s treatment at the time.
“It is an intentional tactic that is trying to make it impossible for providers to satisfy the basic requirement of practicing in the United States,” Baker said.
“Because the United States is such a litigious society, providers have to have malpractice insurance, which is best practice to make sure if folks in some way are injured or subjected to malpractice in receiving medical care, they can pursue recourse,” he continued.
“But, in many cases, this is taking that concept and perverting it to turn it into a weapon specifically to drive providers away from practice and make it impossible for trans people to receive that care.”
According to Baker, many stakeholders in the gender-affirming healthcare space fear that more providers will deny coverage.
He said those seeking to block gender-affirming care at the state level are trying to “throw anything they can think of at the wall and seeing what can stick.”
He said it’s part of a larger effort to make it impossible for trans and gender-diverse young people to access “medically necessary care they need that has been prescribed by their doctors and, if they are minors, agreed to by their parents.”
Baker stressed that we see “incredible overreach” by government leaders to “push aside healthcare providers who are operating in evidence-based standards in the field” and insert themselves into the doctor-patient relationship.
Dawson noted that more states will likely propose and enact gender-affirming care bans and insert these liability provisions.
She pointed to KFF research that showed in June 2022, only four states enacted these policies, which she described as a “fast uptick.”
Certainly, many more states followed suit over the course of the following year.
“Just as the environment is shifting in state lawmaking, it is also continuously shifting in litigation challenging these laws, often on constitutional grounds,” Dawson explained.
“There is legal action challenging these laws in about three-quarters of the states that have enacted them, and in some cases, courts have blocked the laws from being in effect. Additionally, the families in a Tennessee lawsuit, along with the [U.S.] Justice Department, have asked the Supreme Court to review their case. The landscape is evolving rapidly in terms of both lawmaking and legal challenges,” she added.
Despite the challenges faced by LGBTQ+ young people and their families, it’s important to highlight how impactful it can be when gender-affirming care is made accessible.
Recently, The Trevor Project released new survey findings that asked young people one simple question:
“What are things that others do that make you feel happy (or euphoric) about your gender?”
Gender euphoria refers to the sense of joy and fulfillment that can result when a person’s experiences with their gender align directly with their gender identity, as opposed to the gender they were assigned at birth.
The survey examined data from the 2023 U.S. National Survey on the Mental Health of LGBTQ Young People, with 9,074 trans and nonbinary young people responding to that question via text message responses.
In some examples, one young respondent said, “Honestly, just calling me by the proper name and pronouns makes me so happy.” Another said they felt euphoric when others would “treat me like a normal guy” or “not [treat] me differently because of my gender identity.”
Another person expressed euphoria “when the only friend I’ve ever told about my gender questioning said she would support me in whatever identity I use.”
In short, just respecting someone’s gender identity and affirming it can change someone’s self-esteem and outlook on life.
But theterm “gender euphoria” is not a new concept.
According to DeChants, it has been used by transgender and nonbinary communities since 1976. Despite this, he said the “topic of gender euphoria has not been frequently discussed in larger conversations around LGBTQ youth mental health.”
“We so often hear about gender dysphoria, which is a deep sense of discomfort or unease when there is a disconnect between one’s gender identity and their sex assigned at birth,” DeChants told Healthline.
“While gender dysphoria and the negative mental health outcomes associated with it has been heavily researched, gender euphoria has not been widely studied.”
DeChants stressed that this is “an integral part” of the experience of being trans and nonbinary. While it’s necessary to highlight the challenges that exist for trans and gender diverse youth, it is crucial “that we highlight moments of positivity and joy when discussing gender identity.”
“Trans and nonbinary people are not a monolith, and their experiences and emotions are beautifully diverse, just as any other group or community,” DeChants added.
DeChants noted he wasn’t expecting the survey results to show such a high volume about appearance affirmation “and how impactful a simple action like giving someone an affirming compliment can be.”
“The Trevor Project’s research shows that 41% of LGBTQ young people seriously considered attempting suicide in the past year, including half of transgender and nonbinary young people. Our data also shows that affirming gender identity among transgender and nonbinary young people is consistently associated with lower rates of attempting suicide,” DeChants added.
“When peers and loved ones work to foster safe and affirming environments where trans and nonbinary youth can express themselves fully and freely, this can have a direct impact on reducing anxiety, depression, and suicide risk.”
As anti-gender-affirming care legislation becomes more complex, what can young people and their families do to cope? How can they access the care they need if they live in a state that has passed or is proposing this legislation?
“Unfortunately, this is a situation where minors with the most privilege in terms of family support and financial resources may have access to gender affirming care while those who do not have this privilege are left without care,” Dawson said.
“There have been reports of some families moving in order to continue care and there is the potential to seek care across state lines, but again, this requires the support of families and financial resources. The laws and differences among families to secure this care have led to a patchwork of access across the country.”
Baker echoed those points, saying the issue is about economic justice and racial justice.
Anti-gender-affirming care legislation disproportionately affects young people and families who live at the economic margins and don’t have the financial means to relocate or receive adequate health coverage.
More often than not, this intersects directly with People of Color who live in areas with limited access to quality medical care and face barriers to receiving life-saving healthcare. In these places, medical racism is often all too prevalent, fueling health disparities.
“The answer of ‘just get out,’ has those racial justice implications, economic justice implications. We cannot afford to leave people behind on the basis of who can afford to get out [of a given state] versus who can’t,” Baker said.
“It has become a very complicated — and for providers, patients, and families — a very anguished discussion of what is possible to do, to maintain the places they live, to keep their jobs, to not be chased out of their homes. There really, right now, is no good answer to what those families should do. And none of the states that are passing these bans care at all.”
Baker explained these disparities are “taking an already marginalized group of people and kids and targeting them for bullying.”
“Denied access to gender-affirming care has been linked to negative mental health outcomes for transgender youth, including with respect to suicidal ideation,” Dawson noted.
“This is on top of already existing mental health disparities. Conversely, access to gender-affirming care has been associated with improvement in these domains. In addition, aside from actually having care blocked, having LGBTQ+ rights debated on local and national platforms could challenge the community’s well-being,” she added.
When asked to point to some resources families and young people can turn to, Baker named two resources:
He added there aren’t many quality resources for healthcare professionals trying to navigate the issue, as medical malpractice laws may vary from state to state.
“This isn’t about reform, this is about finding new and inventive ways to bully provider, patients, and parents. It is not something that our elected politicians should be spending time on, they should be working to actually get families and communities the care and support and resources that they need,” Baker added.
“It is very important to highlight the ways in which, again, these ‘reforms’ are nothing more than a continuation of the same political agenda that is trying to use parents and kids as a political wedge issue.”