Last year, bills prohibiting healthcare for trans youth were introduced in more than 20 states, with two states—Arkansas and Tennessee—signing them into law, according to a tally from the American Civil Liberties Union (ACLU).
Last month, Texas Governor Greg Abbott issued a directive that parents of trans children be investigated for child abuse. This month, a Texas court temporarily blocked the directive, but the policy's current legal status remains unclear. The state filed an appeal soon after the temporary injunction, and groups like the ACLU have asked an appeals court to clarify its position.
“It really takes a toll on an individual's fear,” Colin Quinn, co-founder of startup Included Health and president of Included Health Communities, a care concierge solution for the LGBTQ+ community, told Fierce Healthcare. Afraid of the potential repercussions for disobeying such directives, providers and patients alike may start to wonder, “Gosh, maybe I shouldn’t do this,” he said.
Last fall, pressure from the governor's office quietly shut down the state's largest gender-affirming care program, The 19th recently revealed.
Healthcare leaders say the damage has already been done: Stigma and discrimination are worsening, some providers have stopped offering hormone therapy, trans youth and their parents are in anguish and some have already begun to be investigated by state officials.
Since Abbott's directive, a nonbinding opinion not based in science, was published in February, more members have been reaching out to the care team at Included Health Communities with concerns about their access to gender-affirming care, Quinn said. Some have reported being denied by their long-time physicians in Texas. Others are weighing whether to move to another state entirely. Employer clients, too, have been reaching out with questions about how best to support their members during this tumultuous time.
In the wake of state policies being introduced to prohibit medically necessary gender transition-related care for minor patients, employers are showing more interest in offering these services to their adult employees, some LGBTQ care startups report.
“No matter where you live in this country,” said Ellen Kahn, senior director of programs and partnerships at the Human Rights Campaign, “you’re not immune to what’s happening in some of these more conservative states.”
Even on a local level within a community, she said, “you come up against people with transphobic attitudes every day.” That's why it is critical to be checking in on trans and nonbinary youth and their families.
Though trans people are gaining more visibility in the U.S., experts agree there has been an acceleration of these types of bills and actions in the past several years. In 2021 alone, a record year, more than 100 bills were introduced targeting trans rights; Texas introduced triple the number of any other state.
“Just by them being proposed and talked about is creating misinformation, creating additional fears, creating additional stigma,” Quinn said.
“Even these opinions can have massive ramifications for the care of trans people,” echoed Jerrica Kirkley, M.D., Plume’s chief medical officer and co-founder. “It does impact everybody; that’s the bottom line.”
Though Abbott’s directive does not apply to Plume directly, as the company does not provide care to minors, Kirkley and her team—more than half of which are trans—feel compelled to advocate on behalf of the community. One way it’s doing so is directing people to local resources, relying on groups like the Transgender Education Network of Texas to determine access points of care.
“There are lots of ways you can use your influence even though you are not, you know, the CEO of a large hospital,” Kahn said. One way she suggested is to call elected officials.
That’s exactly what Kirkley has been doing—speaking with lawmakers on the safety and necessity of gender-affirming care like hormone therapy and advocating for the expansion of telehealth, Kirkley explained.
In April, the American Medical Association (AMA) urged governors to oppose state legislation that would prohibit medically necessary gender transition-related care for minor patients, calling such efforts “a dangerous intrusion into the practice of medicine.” In a letter to the National Governors Association, the AMA cited evidence that trans and non-binary gender identities are normal variations of human identity and expression and that forgoing gender-affirming care can have tragic health consequences, both mental and physical.
“Decisions about medical care belong within the sanctity of the patient-physician relationship,” the AMA wrote in its letter.
According to one recent study, recipients of gender-affirming care, including puberty blockers and hormones, had a 60% lower chance of moderate to severe depression and a 73% lower chance of suicidality within a year. Other 2019 figures from The Trevor Project revealed that more than half of trans and non-binary youth have had suicidal thoughts in the past year, and nearly a third made a suicide attempt.
The medical community needs to continue to work together to advocate for patients and provide care when legal, experts say.
One of the main ways to sustain the work is the ongoing clinical and cultural training of the medical community on the needs of trans people, Kirkley stressed. There should be attention to and compassion across every element of a provider’s care, down to having inclusive bathrooms. While there may be a few well-trained employees at a practice, that isn’t enough. A coordinated approach—not only in times of crisis, but daily—is necessary to nurture a safe, comforting, gender-affirming environment.
“It’s always great to have champions,” Kirkley said, “but if the system at large is not supportive, it starts to undermine what one or two people can do.”