Access to Gender-Affirming Care Is Under Threat—Here’s Why That’s Harmful

Graphic: W+G Creative
The LGBTQ+ community is no stranger to persecution, but the current political climate in the United States has made seeking a happy, healthy, and safe life a challenging (if not impossible) pursuit for this demographic. For trans and gender non-conforming folks, in particular, intended limits or all-out bans on gender-affirming care in many states has compromised safety even more.

“Gender-affirming care is the steps one takes in order to affirm who they are and feel a better sense of belonging in their bodies and in this world, and it can encompass a variety of things,” says transgender athlete and activist Chris Mosier. Exactly how gender-affirming care looks is different for everyone, but there are two main components: social transitioning and medical transitioning—and they’re under attack by lawmakers, particularly for minors, he says.

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In just the last few years, 20 states have passed laws or policies banning or restricting access to gender-affirming care for youth. Montana, Idaho, Utah, North Dakota, South Dakota, Texas, Iowa, Missouri, Indiana, Kentucky, Tennessee, and Mississippi have passed full bans. West Virginia, Arizona, Nebraska, and Georgia have passed partial bans. And in Alabama, Arkansas, Oklahoma, and Florida, laws banning or restricting access to gender-affirming youth have passed but are being temporarily blocked (in some cases partially) by legal challenges. Seven other states—Oregon, Wisconsin, Michigan, Ohio, New Hampshire, North Carolina, and South Carolina—are considering or have considered similar laws banning access to gender-affirming care for youth. Some states, such as Florida and Missouri, are also introducing restrictions that would regulate access to gender-affirming care for adults.

Socially rooted gender-affirming care might include emotional or community support around non-medical transitions, like name or pronoun changes and non-permanent shifts in appearance, like haircuts or clothing style. And these are the forms of care that most trans young people seek, says Mosier of social gender-affirming care: “It’s about allowing people to dress how they want and to use the names and pronouns that affirm who they are.”

Access to gender-affirming care is an essential right that must be protected in order to ensure that trans and non-binary people are able to live healthy lives.

In other words, the bulk of care for young people involves non-permanent changes. And while current anti-trans legislation mostly takes aim at medical gender-affirming care, Mosier says such attacks can make social transitioning, or accessing care around social transitioning, feel less safe.

Gender-affirming care—medical and social—is safe and beneficial to the mental health of trans and non-binary individuals. Limiting or eliminating its availability jeopardizes the well-being of the person seeking it—not the person aiming to restrict it. Access to gender-affirming care must be protected in order to ensure that trans and non-binary people are able to live healthy lives.

The positive power of the gender-affirming care that’s under attack

Medical gender-affirming care mainly includes treatments such as puberty blockers and gender-affirming hormone therapies. Puberty blockers buy young people more time to decide how they want to proceed with their care by delaying the onset of puberty, says Kate Steinle, nurse practitioner and Chief Clinical Officer at FOLX Health—a digital health-care service for the LGBTQ+ community. Hormone treatments are then the next step, or potentially the first medical step for an individual who has already been through puberty, in transitioning.

“Someone who was assigned male at birth might take estrogen or a testosterone blocker for their care, and that would be for their lifetime,” says Steinle. “Those medications are going to help that person become less gender dysphoric, to be able to see their body or their voice or whatever parts they might have dysphoria about come into alignment with their gender identity.”

According to Steinle, puberty blockers and other hormone-based medications are prescribed in the same way any other medication is prescribed: following a clinical diagnosis, lab work, and all other standard protocols. (That said, the Food and Drug Administration (FDA) has only approved puberty blockers to treat precocious (or early) puberty, and its efficacy as gender-affirming care is an off-label use.)

There are also many steps in the transition process before such medications are even introduced. “Young people are working closely with parents and health-care providers and mental health-care providers to determine what sort of changes to make at any given time that are age appropriate and in the best interest of that young person,” says Mosier.

Treatment for minors only rarely involves surgery and that's a step only taken after many years of professional medical evaluation, says Kate Steinle, nurse practitioner and Chief Clinical Officer at FOLX Health.

Despite disinformation to the contrary, treatment for minors only rarely involves surgery and, says Steinle, that's a step only taken after many years of professional medical evaluation. (And certainly, no one is operating on very young children, as some would suggest.) An analysis of insurance claims in the United States conducted by Reuters and health technology company Komodo Health Inc last year found that just 56 individuals between the ages of 13 and 17 with a prior diagnosis of gender dysphoria underwent genital surgery between 2019 and 2021. Top surgery for teenagers is more common but still statistically rare, according to the analysis. (That said, the study authors acknowledge it may be an undercount because the number doesn’t include procedures paid for out of pocket). In that same three-year time span, 776 mastectomies were performed on individuals in the same demographic.

Many of the proposed bills banning gender-affirming surgery for trans youth include exemptions for intersex children, too, which is further evidence of a bias against transgender and non-binary individuals. Intersex surgeries are performed on infants and children, who have sex organs or characteristics that don’t neatly fit into a biological male or female binary in order to align the child's genitalia more closely with one gender or the other. These children are often too young to consent, and by exempting intersex surgeries from these bills, lawmakers are further demonstrating that their stated intent—to protect children–is a bad-faith argument

And while it’s true that some percentage of those who receive gender-affirming surgery may eventually come to regret it, such regret is extremely rare. “This discourse is just a scare tactic,” says Steinle. “In any surgery, there’s going to be a small percentage of people with regrets.” And if this were truly the concern, Steinle says these bills would also be banning cosmetic surgery for cisgender minors.

What science says about the safety of medical gender-affirming care

Puberty blockers have been prescribed to cisgender children with precocious (early) puberty for decades. “These are medications that have been used over time and have been proven safe and effective,” says Mosier, who adds that numerous studies have examined the mental health impact of gender-affirming care on trans youth, and results have landed in overwhelming favor of the treatments.

Trans youth have high rates of depression, anxiety, and suicidality, and gender-affirming care has been shown to help. “Existing evidence suggests that gender-affirming medical care has favorable mental health outcomes for young people,” says Mosier.

“We can see through study after study that when people do not have access to gender-affirming hormones, mental health issues skyrocket.” —Steinle

And on the flip side, there’s significant evidence to support that harm is done by limiting access. “We can see through study after study that when people do not have access to gender-affirming hormones, mental health issues skyrocket,” says Steinle. “Depression and anxiety and suicidality are extremely high risks when people do not have access to care.”

Because of this evidence, an overwhelming number of major medical organizations—the American Academy of Pediatrics, the American Medical Association, the American Psychological Association, and more—support access to gender-affirming care. “It’s so clear to people who have worked in this field for a long time that this is a safe and effective treatment for people who are trans or non-binary,” says Steinle.

Where the legislation may be headed—and how to help

While the bulk of bans on gender-affirming care are, at this point, focused on access to gender-affirming care for minors, some are targeting access for adults as well. In fact, Steinle says the law that was just temporarily and narrowly blocked in Florida, SB 254, included regulations around gender-affirming care access for adults. “Specifically, [the law said] the only people who could prescribe gender-affirming care for adults were MDs or DOs, and so any of the nurse practitioners or physician's assistants who were already caring for a lot of these patients could no longer care for them,” she says. The law also stipulated that patients see these doctors to sign informed consent forms in person, which Steinle says could be another barrier to care for those who live in care deserts or otherwise rely on telehealth services.

Mosier and Steinle see this law as a possible test case for many coming attempts to regulate access to gender-affirming care for adults. “The easiest idea to rally people around is, ‘Protect the children,’ but they won’t stop there,” says Steinle. “They want to politically and culturally eradicate trans people. It's very clear in the language that they use that the only acceptable way to be is to be cis.”

“We are moving toward a reality where if you’re not a straight, white, cisgender person of a certain socio-economic bracket, your rights are at risk.” —Chris Mosier, transgender athlete and activist

These attempts at limiting freedoms should be troubling to everyone, says Mosier—not just members of and allies to the LGBGQIA+ community. “The attacks on the trans community are deeply related to the attacks on bodily autonomy for people who can become pregnant, and the attacks on Black and brown individuals in our country who, when we layer in the intersections of identity, are disproportionately impacted by these bills and laws,” says Mosier. “All the things we’re seeing happening in this country—abortion rights and voting rights and redistricting and voter suppression—are moving toward a reality where if you’re not a straight, white, cisgender person of a certain socio-economic bracket, your rights are at risk.”

The first thing you can do to help is educate yourself. “There's a real lack of understanding around transgender and non-binary people in general, from basic terminology and concepts all the way up to what our care is, what being in sports is like for us, and so on,” Mosier says. “This is a much more nuanced conversation than can be conveyed in a headline or tweet, and it needs to be—because we're talking about people's humanity.”

With regard to that self-education, Mosier concedes that it can be hard to know where to turn for accurate intel. Steinle recommends the library at FOLX as a resource, and both she and Mosier say the best sources of information more generally are the people who work and live in this space—trans and non-binary people themselves, and the clinicians who provide them with care.

Once you’ve begun the ongoing process of educating yourself, Mosier says it’s important to speak up, whether that means helping to inform friends and family or publicly speaking out against disinformation, myths, and lies around gender-affirming care and other trans-rights issues.

Steinle says that those with financial resources can also donate to the FOLX HRT Care Fund, which gifts grants for free care—e.g. medications and clinical care—through FOLX for those in need.

If you don’t have financial resources to spare, Steinle points out that there is something far more simple, and equally impactful, to be done: Reach out to those in the LGBTQIA+ community to show your support. “This is a scary time for people, so it’s important for individuals to reach out to their friends or family members who are in the LGBTQ community to show them they’re loved, they’re important, they’re amazing and beautiful regardless of all the crazy loud political theater saying otherwise,” she says. “We have to remember to offset that language with language of acceptance and love.”

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