Last month, the American Medical Association (AMA) passed a resolution to protect access to gender-affirming care, committing to opposing criminal and legal penalties against patients, their families and providers.
The resolution was in part a reaction to Florida bill S.B. 254, signed into law in May. Approved by Gov. Ron DeSantis, the law imposed restrictions on adult access to gender-affirming care.
A separate part of the bill, which banned gender-affirming care for minors, has been temporarily blocked by a judge. The law reportedly misrepresents published data on gender-affirming care and goes against the recommendations of major medical associations, including the American Academy of Pediatrics, the American Psychological Association and the Endocrine Society. It is currently being challenged in court.
Under the new law, adults seeking gender-affirming prescriptions or procedures must sign an informed consent document in person with an M.D. or D.O. The form is approved by the Florida Board of Medicine and Osteopathic Medicine, a group whose members are directly appointed by DeSantis. After that, the patient needs to be treated, in-person or virtually, by that same physician. Florida has the second-largest population of trans adults in the U.S. behind California.
Additionally, before beginning hormone therapy, adults are required to have a psychological evaluation performed by a Florida-licensed psychologist or psychiatrist and then every two years thereafter. At the end of June, the Florida Board of Medicine adopted an emergency rule giving patients already on treatment six months to adapt to the new requirements.
Some gender-affirming care providers have been forced to stop serving new or existing patients in some capacity. Others are finding temporary workarounds.
Nurse practitioners, most of whom prescribe medications and deliver primary care, are no longer authorized to prescribe gender-affirming hormone therapy. Neither are clinicians who see patients over telehealth. Providers say the new requirements further strains an already overburdened system with a shortage of physicians.
“They can make all the emergency rules they want,” Joseph Knoll, founder and CEO of Florida-based LGBTQ+ clinic Spektrum Health, told Fierce Healthcare. “There simply aren’t enough physician providers for this care, so it has interrupted care for thousands and thousands.”
The new law doesn’t prohibit nurse practitioners from prescribing hormones in general, Knoll noted. It only prohibits it for people with gender dysphoria. They can still prescribe the same medication to cisgender patients for other purposes.
“This is very clearly discrimination,” Knoll said.
When providers first heard of the bill, they began preparing contingencies. Virtual providers Plume Health and Folx Health got doctors on the ground via pop-up clinics and appointment-only hubs for members. To staff them, both companies had to hire additional physicians licensed to practice in the state.
“The impact that this has on the medical community and on providers has just been so massive and so stressful,” Folx Health COO Dana Clayton told Fierce Healthcare. Folx currently has five hubs around the state, with plans to add three more.
Before the bill was signed into law, Folx Health had about 1,500 patients in Florida, all on hormones. Since the law was passed, Folx saw double its typical amount of weekly signups of new patients, per Clayton. Plume Health has about 850 patients in the state, most of whom are also on hormone therapy.
As part of its community response effort, Plume launched a free virtual support group to all trans and nonbinary people in the state who wish to join. Over three weeks, they meet to share in solidarity, exchange resources and build supportive connections. The calls are facilitated by a trained peer facilitator.
New requirements, vague language hamstring access to care
Not all providers have been able to staff up. Knoll’s Spektrum Health, a charitable organization, is nurse-led and has never employed physicians since its founding in 2018. Nonprofits like Spektrum “need to be conscious of the bottom line, and physicians make double or triple what nurse practitioners make,” Knoll said.
Not only is there a shortage of providers, but also “it’s hard to attract somebody new to work in this field based on the rhetoric here in Florida,” Knoll said.
Candidates Spektrum has interviewed so far say they want to help, but it is too big a risk for them or their families. Some say to get in touch after challenges to the law play out in court. One provider demanded $500,000 annually—an impossibility for nonprofits like Spektrum, Knoll said.
With the new requirements, doctors are inundated with patients seeking gender-affirming care, which limits face time with their existing panel of patients who may have more acute medical needs, Knoll explained.
Patients are currently seeking endocrinologists who may be familiar with hormone drugs. The problem is they are not trained on gender dysphoria and the correct regimen for this population, Knoll said. In fact, most endocrinologists in his region have historically referred patients to Spektrum.
Planned Parenthood centers in the state—both in Southwest and Central Florida and in the South, East and North—are not currently taking new patients seeking hormone therapy, according to their websites. Like other clinics, Planned Parenthood centers in the state have more nurse practitioners on staff than doctors.
More than half of Spektrum patients are on hormone therapy. Before the law took effect, it was a “mad rush” to get Spektrum patients in as quickly as possible to make sure their labs were up to date and to supply them with six months of hormone prescription refills, Knoll said. At this time, the provider can only monitor them on their current regimen and not prescribe anything new.
Ultimately, the final call on prescription access lies with a pharmacist and a patient’s insurer, Knoll said. Spektrum patients have been turned away at pharmacies amid confusion about the state’s evolving policies.
New Spektrum patients seeking gender-affirming care can only receive primary care at the moment, and the waitlist of those waiting for hormone therapy is long. Spektrum does not offer gender-affirming surgery procedures, Knoll said.
The detrimental effect such bills have on access to care is by design, the providers said.
“A lot of these bills are intentionally written with vague language and that makes them hard to interpret so there can be a lot of confusion when it comes to even understanding the implications of these bills,” Jerrica Kirkley, M.D., co-founder and chief medical officer of Plume, told Fierce Healthcare.
Spektrum is currently building out a coalition of partners with doctors on staff and working with organizations that are challenging the law as a group. Knoll is confident they will prevail in court.
“This law has got to be completely nullified,” Knoll said. “The science is on our side.”