Nationwide bans on transition-related health care could have negative implications for the overall health of transgender youth.
In 2021, Arkansas became the first state to pass a law that would ban access to transition-related health care for individuals younger than 18 years. Since then, transition-related care has been under fire, with 20 states passing laws that would prevent transgender youth from accessing care within their borders, leaving many families with transgender children to scramble for solutions. The move could leave many children without proper care both physically and mentally as these bans persist.
Transition-Related Health Care Threatened
According to the Human Rights Campaign, as of June 1 there are 20 states that have effectively passed laws prohibiting access to transition-related care and an additional 7 that are considering such a ban. The states banning the laws, located primarily in the South and Midwest, contain about 30.9% of all those younger than 18 years who identify as transgender in the United States, or 92,700 individuals. Of these transgender youth, an estimated 39,600 are likely to be most at risk for losing care altogether. Some states, specifically Texas, Oklahoma, and South Carolina, have also proposed laws that would prevent people with gender dysphoria from accessing care until they reach age 26 years.
According to ABC, supporters of the bills are claiming that decisions on transitioning should not be decided until the individual is a legal adult. The governor of Alabama, Kay Ivey, said that children should be protected against life-altering decisions at a vulnerable age. The bills banning transition-related care are among more than 300 bills nationwide that target the LGBTQ community, according to the Human Rights Campaign.
“There are people in the general population who feel threatened because the laws are specifically designed, not to protect children as they claim, but really to go after transgender people and maybe, by proxy, also going after people in the gay population as well,” Jack Drescher, MD, told The American Journal of Managed Care® (AJMC®). Drescher edited the chapter on gender dysphoria in the DSM-5 diagnostic manual, published by the American Psychiatric Association (APA) in 2013.
“Obviously these [bills] were all introduced out of a named idea that action had to be taken to ‘protect children,’” Olivia Hunt, policy director at the National Center for Transgender Equality, told AJMC. “And we've now seen that expand to trying to restrict transition-related health care for adults. So it's pretty clear that for anti-LGBTQ politicians and media figures, who certainly always need a target to fight against, they've decided that going after trans[gender] people's ability to live openly and honestly within society is their goal.”
Immediate Effects: How Do These Laws Affect Transgender Youth?
The APA made a statement in 2012 that individuals with a diagnosis of gender dysphoria should be able to access care including puberty blockers and surgery, marking the first time that the association had taken an official stance on the issue.
“These are treatments that have been proven to be effective by the people who are the experts in this area, and so the APA has supported access to care,” Drescher said.
The APA, along with other organizations such as the American Medical Association, the American Academy of Pediatrics, and the American Public Health Association, recommends access to this care because the effects on youth of not providing the care could be long-term—and both physical and mental.
On the physical side of health, banning access to care within a certain state will require families to look outside state borders for the medication that they need. While some states are allowing minors who started transition care prior to the ban to continue that care, any child seeking treatment for the first time will be at a disadvantage. This could also lead to families moving from the state, Drescher noted.
Hunt said that certain states may be better off if they border states that allow transition care, but those in other states could have a very hard time. “A health care ban in West Virginia would not be as immediately impactful because people would be able to travel to, say, Virginia, Maryland, or [the District of Columbia] relatively easily to access transition-related care from providers there,” she said. “If you happen to live in Florida, where there's been the most sweeping attacks on trans[gender] people's rights to health care, you're not going to have a lot of available options in your neighboring states.”
An increased burden on health care workers in states who do still permit transition-related care is also possible. A story from the Associated Press found that, in one instance, a transgender boy from South Dakota and his family would have to look to Minnesota to receive care.
“It's safe to assume that we are going to see additional burden on places where transition-related care is still more accessible,” Hunt said. She added that those in rural areas would be especially at risk given their more isolated area and the reduction of telehealth visits with the end of the national public health emergency.
Not only physical health will be affected by these bans, but mental health as well. Transgender youth have been found to have an increased rate of mental health issues when they are not supported in their community or by their family.
Drescher pointed to bans on gay marriage that started to sweep the nation in 2004 as a similar catalyst of deteriorating mental health in the LGBTQ community.
“There's research showing how bans against gay marriage led to increased mental health concerns among people in the gay population. So it's not unreasonable to think that the bans thst single out particular children and young people are going to make them feel worse about themselves,” he said.
He also commented that his practice in New York has seen an influx of people who have expressed concern about the bans, even in a state that has protected transgender rights. “I'm seeing in my patient population here in New York, where we are not having bans, that people are coming into treatment complaining about [being] preoccupied with all these bans that are going on. Because people, I think, correctly interpret that these are bans that are attacks on the LGBTQ community,” he said.
Hunt said that acknowledging the names and pronouns of transgender people is one of the easiest forms of health care in terms of the mental relief that occurs in those instances of being recognized. Also, having access to care has reduced mental health burden in youth and adolescents.
“And we've seen that when minors have access to that care, their rates of significant negative mental health outcomes plummet. We're talking [one]-half, two-thirds, three-quarters reductions on issues like severe depression, severe anxiety, and suicidality,” she said.
A Path Forward: How Do We Keep Caring for Trans Youth?
Both Drescher and Hunt emphasized that transition care has been found to be safe and effective for decades prior to these bans.
“People have been treating people with gender dysphoria with surgery for about 100 years, [and] with medication when hormones came on the market. So this has been going on,” Drescher said.
“[Hormones] have been studied for decades. We know what the effects are, and attempting to portray them as somehow dangerous for trans[gender] people, but not for cisgender youth who received them for precocious puberty or to deal with some medical issues related to puberty, again, shows that this is not in any way driven by a concern that the medications are in any way inappropriate,” Hunt said.
A similar point was made by US District Judge Jay Moody in his ruling in Arkansas that placed a permanent injunction on the state’s law that would prohibit access to transition-related care. Moody said that treatment for gender dysphoria was not “experimental” as Republican Attorney General Tim Griffin claimed. Judge Moody also went on to note that prohibiting medical care that has improved the mental health and well-being of those who take it undermines the interests that those who passed the law claimed to prioritize.
“The judge concluded that the reason that they were singling out puberty blockers for transition services has really had to do with animus and discrimination against people in the transgender community,” said Drescher. “And I would say that's a reasonable assumption.”
Both Drescher and Hunt said that education on the topic is vital to get people to understand what transition health care really is.
According to Drescher, psychiatrists can lead in a more educative role in the future by speaking in places where these bans are taking place. “Educating policy makers, educating journalists, educating the general public, and issuing position statements and putting up information on our website to answer questions that people have. Because not many people know that much about this. Everybody has opinions about it, but not everybody knows much about it,” he said.
Hunt said that her work with the National Center for Transgender Equality has been focused on teaching the public about transgender people outside of the stereotypes and portrayals seen in media. “I like to view all of the work that we do, whether it's policy work, whether it's organizing, whether it's even our social media presence, as public education. We're trying to get the word out to people [so] they understand who we actually are,” she said.
Challenging people’s assumptions based on media is an important way to educate on the topic. Having policy makers and politicians speak with their constituents who identify as transgender could be a helpful way of making the laws more personal, Hunt suggested.
“We are not new, we've always been here. It's just that...outside of the LGBTQ community, for the most part, people just generally never paid attention to us until it became politically expedient for anti-LGBTQIA politicians to start targeting us,” she said.