Bans on gender-affirming care have 'chilling effect'

Twenty-five U.S. states have now limited at least some form of gender transition-related health care such as hormone replacement therapy, with laws mostly impacting minors’ access to such care. 

That means 1 in 3 transgender youths are living in a state “where they are categorically barred from accessing lifesaving health care,” said Rodrigo Heng-Lehtinen, executive director of the National Center for Transgender Equality, during a webinar hosted by Bloomberg Government to discuss health policy developments. “And for the rest who don’t live in a state banning [gender-affirming care], we are already seeing a chilling effect.” 

Similar to states with strict abortion restrictions, states prohibiting gender-affirming health care are seeing doctors and medical centers becoming increasingly hesitant to provide that care, he added. In states like Missouri and North Dakota, for instance, medical providers have stopped offering transitional treatment. 

Experts warn an exodus of physicians willing to provide gender-affirming care could worsen health disparities for members of the LGBTQ community and exacerbate mental health-related conditions of individuals grappling with their own gender identity. 

Gender-affirming care is recognized by leading medical organizations, such as the American Medical Association whose CEO James Madara wrote a letter to the National Governors Association in 2021 warning governors of the potential negative impacts of restricting transgender care. The AMA published the letter in response to Arkansas’ SAFE Act, the first bill in the nation that banned transitional medical care for minors.  

Madara wrote in the letter: “Transgender individuals are up to three times more likely than the general population to report or be diagnosed with mental health disorders, with as many as 41.5 percent reporting at least one diagnosis of a mental health or substance use disorder.” Mental health distress among transgender youth often stems from gender identity discrimination and social stigma against transgenderism, putting these individuals at a “significantly heighted risk of suicide.” 

Bans on gender-affirming care don’t just affect minors, Heng-Lehtinen said. Typically policymakers have targeted care for youths ages 13 to 18, but recent legislation increasingly expands that age range. 

Policymakers in Kansas, Oklahoma and Texas have introduced bills to prohibit health care providers from providing gender-affirming care for adults up to age 26. Earlier this week, South Carolina was the latest state to pass legislation banning gender transitioning care for minors and adults after Gov. Henry McMaster signed a bill that would prohibit medical professionals from performing gender-transition surgeries, prescribing puberty blocker medication and overseeing hormone treatments for minors. It also restricts the use of Medicaid funds to cover such care for adults under 26 years. 

More broadly, transgender adults are reporting that they fear or have had negative experiences in medical settings due to their gender status. Data from the 2022 U.S. Trans Survey shows 24% of the 92,329 adult respondents said they did not see a doctor when they needed to in the last 12 months due to fear of mistreatment. Of the transgender adults who did see a medical provider in that time frame, 48% of respondents said they had at least one negative experience such as being refused services, being misgendered or being spoken to with “harsh or abusive language,” the study stated. 

Not only are state legislatures raising the age threshold under which gender-affirming care is restricted, they are also proposing increasing numbers of bills to limit transgenderism in general. “This is a very modern phenomenon,” Heng-Lehtinen said. “It was only in the last three years, really since 2021, that we saw a sharp, dramatic, exponential increase [in anti-transgender bills].” 

Over the last decade, an average of 40 anti-transgender bills were proposed across the states each year, he said. But there were at least 510 such laws introduced in state legislatures in 2023 alone. Nearly 150 of the bills restricted transgender individuals’ access to transitional care, but lawmakers are also limiting public drag shows and LGBTQ-related topics in school curriculum.

Other state lawmakers are ramping up their efforts to limit transgenderism outside of the medical setting. Last year, Wisconsin policymakers, for example, introduced a bill that would bar an individual assigned male at birth from participating on a women’s sports team. 

It was vetoed by Gov. Tony Evers, who wrote in his April veto letter, “[T]his type of legislation, and the harmful rhetoric beget by pursuing it, harms LGBTQ Wisconsinites’ and kids’ mental health, emboldens anti-LGBTQ harassment, bullying, and violence, and threatens the safety and dignity of LGBTQ Wisconsinites, especially our LGBTQ kids.” 

In Florida, the Department of Highway Safety and Motor Vehicles recently issued a memo banning transgender individuals from changing the sex on their driver’s license to reflect their gender identity. 

“Permitting an individual to alter his or her license to reflect an internal sense of gender role or identity, which is neither immutable nor objectively verifiable, undermines the purpose of an identification record and can frustrate the state’s ability to enforce its laws,” wrote the department’s executive director Robert Kynoch.

On such gender identification requirements, Heng-Lehtinen said a driver’s license that doesn’t reflect how a person presents themselves could be a “forced outing,” or reveal an individual as transgender without their desire to do so. That increases the risk of facing stigmatized, discriminatory behavior from others that wouldn’t have happened otherwise, he added. 

The rise in anti-transgender legislation hints at the deterioration of democracy, said Skye Perryman, president and CEO of Democracy Forward Foundation, a nonprofit public policy research organization. “Data and research show us that there is a relationship between the position of women … and other historically marginalized groups like LGBTQ people and the overall strength of a democracy.”