Protecting Progress in LGBTQ+ Health Care 10 Years After Obergefell

June 26, 2025, marks 10 years since the Supreme Court’s Obergefell v Hodges decision legalized same-sex marriage nationwide;¹ the decade since has comprised a series of efforts that moved the needle on improving health and closing gaps in access for LGBTQ+ individuals.

However, that decade's worth of progress took a sharp turn with the return of the Trump Administration.² After a flurry of executive orders targeting diversity, equity, and inclusion (DEI) initiatives, especially those related to the LGBTQ+ community, followed by Robert F. Kennedy Jr's appointment as Secretary of HHS, bringing about reductions in workforce and the restructuring of the health centers that make up the department, alarms have been sounding since January.

Notably, lead plaintiff Jim Obergefell warns that marriage equality is under renewed threat.¹ Amid a growing wave of anti-LGBTQ+ legislation and political hostility, Obergefell and other advocates are expressing concern that the hard-fought rights secured could be undermined. According to the article in Axios, the current political climate, shaped by a surge in anti-trans policies, state-level attacks, and emboldened conservative leadership under Trump’s second term, has cast a shadow over the anniversary of what was once seen as a milestone victory for civil rights.

Although federal recognition of same-sex and interracial marriage was signed into law with President Biden's "Respect for Marriage Act" in 2022, it doesn't block states' efforts to ban or restrict same-sex marriage if Obergefell were overturned.

Regardless, Obergefell urges people to engage in protecting "all the progress we've made in this country for civil and human rights... Never did I expect in 10 years that I would be worried about Obergefell being overturned, that I would be worried about the loss of marriage equality, that I would be worried about so many rights being taken away," he stated in the Axios article.

Pride and Progress in Gender-Affirming Care

The last decade saw significant strides in LGBTQ+ inclusion in health care, clinical research, and guidance, with expansion in access to gender-affirming care, supported by updated clinical guidelines and broader insurance coverage.³ Leading medical organizations, including the World Professional Association for Transgender Health and the Endocrine Society, released new guidance in 2022 outlining evidence-based standards for providing gender-affirming care.

These guidelines emphasize the importance of individualized, multidisciplinary care that addresses the physical and mental health needs of transgender and nonbinary individuals, including access to hormone therapy, surgical procedures, and psychological support.

The evolving medical consensus was accompanied by policy changes that improve access to care. Many public and private insurers, including Medicaid programs in numerous states, had expanded coverage for gender-affirming services. This includes coverage for hormone replacement therapy, mental health counseling, and surgical interventions such as chest reconstruction and gender-affirming genital surgeries, marking critical steps in reducing barriers to care and addressing health disparities experienced by transgender individuals.

HIV Research and Treatment Accessibility

HIV prevention and treatment is another area of health care that disproportionately affects LGBTQ+ individuals and has progressed significantly since the Obergefell decision. Earlier this month, the prevention of HIV became even easier with the FDA approval of lenacapavir (Yeztugo; Gilead Sciences), a twice-yearly long-acting injectable treatment that can prevent HIV.⁴ For those who prefer an injectable form of pre-exposure prophylaxis (PrEP), this approval reduces the number of injections needed from 6 per year to just 2, potentially improving adherence in those who had difficulty attending bimonthly clinic appointments.

The initiation of PrEP has been a game-changer among efforts to address HIV prevention. In 2021, the FDA approved cabotegravir extended-release injectable suspension (Apretude), the first long-acting injectable for HIV pre-exposure prophylaxis (PrEP), reducing barriers tied to daily pill adherence.⁵

In 2016, the Undetectable = Untransmittable initiative was launched with the Prevention Access Campaign—a health equity initiative with the goal of ending the HIV/AIDS pandemic and HIV-related stigma.⁶ Global campaigns and clinical research solidified the understanding that individuals with HIV who achieve viral suppression cannot sexually transmit the virus, reducing stigma and promoting treatment engagement. Although the clinical data supporting this had been accumulating for a decade, researchers from the National Institute of Health (NIH) deemed the concept as "scientifically sound" in 2019 as "an overwhelming body of evidence has emerged to provide the firm basis."

Dismantling Progress

Even with the efforts and advances made in health care inclusion for the LGBTQ+ community, gaps remained in access to care, health disparities, and clinical trial diversity before Trump set forth his executive order⁷ denouncing gender identity outside of male or female established "at conception."

In June 2024, the FDA released a draft guidance aimed at improving the enrollment of participants from historically underrepresented populations in clinical studies involving drugs, biological products, and medical devices.⁸ The agency draft mandated that sponsors submit Diversity Action Plans as part of their investigational new drug applications or premarket submissions, aligning with the regulatory framework established under sections 505(z) and 520(g)(9) of the Federal Food, Drug, and Cosmetic Act.

However, just days after President Trump's return, the White House issued an executive order curtailing DEI programs, and the FDA quietly removed the issued draft guidance from its website. The move, made without public notice or explanation, raised concerns and confusion around the statutory obligations of sponsors.

The final guidance was stated to be legally due this month, June 2025, but appears to be one of many projects nixed by this administration. Although this move may have been subtle, it was followed by the tabling of the mental health parity enforcement rule,⁹ and multiple proposals to defund programs that are critical to LGBTQ+ health, including the CDC of the Division of HIV Prevention,¹⁰ and the 988 LGBTQ+ emergency line,¹¹ despite Trump using legislative action to initially establish the lifeline in October 2020.

Also looming is the Kennedy, Sec. of H&HS v Braidwood Management, Inc. lawsuit, which challenges the Affordable Care Act's requirement for private insurers to cover preventive services without cost sharing, is yet to be determined and will have a particular impact on access to services like HIV PrEP.¹²

How Providers Can Stay Engaged in Affirming LGBTQ+ Rights

Utilizing LGBTQ+-inclusive language in research and in practice contributes to better accuracy in patient data and stronger patient-clinician relationships while addressing existing health care barriers and improving outcomes.¹³ In an interview with The American Journal of Managed Care^® (AJMC^®), Steven Daniel Daveluy, MD, FAAD, associate professor, program director, and clinical educator at Wayne State University, encourages doctors to approach patient interactions with curiosity and respect, acknowledging their own potential knowledge gaps.¹⁴

"I think one of the biggest steps you can take toward addressing unconscious bias is to learn about cultural humility," he said. "We used to talk about cultural competence, but you can't really be competent in someone else's culture. Cultural humility is a different way of looking at it that says, 'I'm going to acknowledge that I will not know as much about your culture as you will, and I'm going to approach it with curiosity and respect.'"

References

1. Lotz A. A decade after Obergefell, LGBTQ+ rights remain under threat. Axios. June 25, 2025. Accessed June 25, 2025. https://www.axios.com/2025/06/25/obergefell-decade-lgbtq-rights-threat

2. Grossi G. Trump’s budget and tax proposals mark historic shift in US approach to health care policy. AJMC^®. June 6, 2025. Accessed June 25, 2025. https://www.ajmc.com/view/trump-s-budget-and-tax-proposals-mark-historic-shift-in-us-approach-to-health-care-policy

3. Munz K. The evolution of transgender health care. AJMC. March 31, 2024. Accessed June 25, 2025. https://www.ajmc.com/view/the-evolution-of-transgender-health-care

4. Bonavitacola J. Twice-yearly lenacapavir approval marks major milestone in prevention of HIV. AJMC. June 18, 2025. Accessed June 25, 2025. https://www.ajmc.com/view/twice-yearly-lenacapavir-approval-marks-major-milestone-in-prevention-of-hiv

5. FDA approves first injectable treatment for hiv pre-exposure prevention. News release. FDA. December 20, 2021. Accessed June 25, 2025. https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention

6. Rosenberg J. NIH researchers say the science is clear: undetectable equals untransmittable in HIV. AJMC. January 16, 2019. Accessed June 25, 2025. https://www.ajmc.com/view/nih-researchers-say-the-science-is-clear-undetectable-equals-untransmittable-in-hiv

7. Defending women from gender ideology extremism and restoring biological truth to the federal government. Executive order. The White House. January 20, 2025. Accessed June 25, 2025. https://www.whitehouse.gov/presidential-actions/2025/01/defending-women-from-gender-ideology-extremism-and-restoring-biological-truth-to-the-federal-government/

8. Grossi G. FDA quietly removes draft guidance on diversity in clinical trials following executive order on DEI. AJMC. January 31, 2025. Accessed June 15, 2025. https://www.ajmc.com/view/fda-quietly-removes-draft-guidance-on-diversity-in-clinical-trials-following-executive-order-on-dei

9. Bonavitacola J. Trump administration walks back mental health parity in insurance coverage. AJMC. May 13, 2025. Accessed June 25, 2025. https://www.ajmc.com/view/trump-administration-walks-back-mental-health-parity-in-insurance-coverage

10. Bonavitacola J. Elimination of Division of HIV Prevention could have consequences for HIV response. AJMC. March 25, 2025. Accessed June 25, 2025. https://www.ajmc.com/view/elimination-of-division-of-hiv-prevention-could-have-consequences-for-hiv-response

11. Bonavitacola J, Wesolowski H. Elimination of specialists for National Suicide Hotline removes important resource for LGBTQ+ youth: A Q&A with Hannah Wesolowski. AJMC. June 24, 2025. Accessed June 25, 2025. https://www.ajmc.com/view/elimination-of-specialists-for-national-suicide-hotline-removes-important-resource-for-lgbtq-youth-a-q-a-with-hannah-wesolowski

12. Grossi G. Health policy in flux: Trump administration updates. AJMC. Updated May 20, 2025. Accessed June 25, 2025. https://www.ajmc.com/view/health-policy-in-flux-trump-administration-updates

13. Santoro C. Inclusive language in dermatology fuels better LGBTQ+ care and research. AJMC. June 4, 2025. Accessed June 26, 2025. https://www.ajmc.com/view/inclusive-language-in-dermatology-fuels-better-lgbtq-care-and-research

14. Santoro C, Daveluy SD. Prioritizing ethical care and understanding in LGBTQ dermatology. AJMC. March 10, 2025. Accessed June 26, 2025 https://www.ajmc.com/view/prioritizing-ethical-care-and-understanding-in-lgbtq-dermatology