Abstract
Since 2020, there has been a significant cultural and political backlash in the USA to growing acceptance of gender diversity and gender-affirming care. Legislative attacks, particularly targeting gender-affirming care access for transgender and gender diverse youth, have occurred in a media environment rife with misinformation and disinformation. Even in states where a ban is not enacted, we have seen significant harm caused by such misinformation and disinformation, to transgender and gender diverse patients, their families, and clinicians who provide this important and much needed care, in the form of clinic closures and disruption of services. In this hostile sociopolitical environment, we present strategies for health care organizations and workers to continue to provide this lifesaving care thoughtfully, to safeguard the protections currently in place, and to continue to advocate for patients, families, and health care staff.
Introduction
Since 2020, we have witnessed an unprecedented rise in anti-transgender bills in the USA, with 600 bills introduced in 2023, 87 of which were passed.1 These bills most commonly seek to limit provision of gender-affirming care, ban participation of transgender and gender diverse (TGD) youth in sports, target students in educational settings by limiting use of correct names and pronouns, mandating reporting to parents, and restricting use of public facilities such as restrooms.1 In March 2023, the Williams Institute estimated that 77,900 TGD youth had already lost access to their gender-affirming care (GAC) across 11 states, while a further 68,400 were at risk of losing their access due to pending legislation in 19 other states.2
The legislative restrictions on GAC have included criminalization of parents3 and health care workers (HCW),4 prohibition of insurance coverage and state funding,4 and limitations on social gender affirmation.4 Even without enactment, proposed anti-transgender laws cause harm to patients and families. Proposed policies have a chilling effect on GAC provision via more stringent restrictions on gender affirmation set by clinics (such as arbitrary age restrictions or increased mental health clearance requirements), targeted harassment of HCW and facilities, and organizational divestment from services due to risk concerns.
If this trend continues, we will witness escalating legislative attacks on TGD youth, their caregivers, and the HCW who provide this necessary care. Given the well-established benefits of GAC5,6 and the importance of continuing to provide this care, health care organizations have an ethical imperative to commit material support to HCW providing GAC and ensure continuity of care for patients. This article presents considerations and practical strategies for GAC programs and clinicians on how to continue to care for TGD patients in this challenging sociopolitical environment. The authors of this article include two physicians in a state without current restrictions on GAC who have directly cared for patients and families who moved to safeguard their access to GAC, two leaders of primary care associations in states where GAC restrictions exist, and two public and community health professionals.
Maintaining Continuity
In states that have enacted GAC bans, HCW must refer patients and families to nearby states, such as referrals from Kentucky to Ohio.2 This requires significant financial resources from individual families. HCW struggle to build knowledge of available resources and coordinate transfers of care. Unfortunately, even these referrals are jeopardized in states that ban not only direct provision of care but also aiding and abetting (such as Iowa).2 In Boston-based practices, for example, increasing numbers of out-of-state families seek GAC, with some families relocating entirely.
Even for families in non-restrictive states, there are many barriers to accessing GAC. TGD patients experience significant economic discrimination and thus are more likely to experience difficulties with transportation, housing, jobs, and health insurance, which are all necessary to consistently remain in care.7 Cisgender caregivers also experience similar stigma and social isolation.8,9,10
Additionally, in a politically and socially fraught environment rife with misinformation and disinformation, providing culturally responsive and linguistically appropriate care for each individual patient and family is especially important for building trust and rapport. Availability of interpreter services is essential for meaningful informed consent discussions with patients and families best served in a language other than English, to be able to fully address any questions, misconceptions, or concerns about GAC. Health care organizations providing GAC should seek to address health disparities by ensuring appropriate social work supports, access to interpreters, diverse staff representative of the patient population, and flexible clinic policies that recognize the socioeconomic constraints of patients and families and do not penalize patients and HCW for late appointments or no-shows.
Improving Access
Many observers view GAC, particularly for minors, as specialty care. Most centers providing GAC have months-long, if not years-long, waitlists. To address this supply-side shortage, innovative, universal, and often mandatory GAC educational programming has emerged, including a GAC training pathway for primary care staff interested in providing such care.
While local adaptation and champions are crucial for the success of such programs, nationally recognized resources such as the National LGBTQIA+ Health Education Center at The Fenway Institute can provide a starting point for new educational programs. If mandates for universal training and provision of GAC are not feasible within a department or across an entire clinical practice, identifying local champions for GAC, and developing in-house expertise, is essential. Educating and recruiting new HCW dedicated to GAC, operationalizing and codifying GAC protocols, and thoughtful “succession” planning will help mitigate the risk of disrupting care for an entire patient panel if a GAC clinician were to leave the practice.
In states that have not restricted GAC, HCW can advocate to expand care coverage to more interventions, such as hair removal or voice therapy, and to mandate coverage by insurance companies on the basis of medical necessity.
Legislative Support
In 2023, every state in the USA except Delaware introduced anti-TGD legislation, often under the pretense of protecting parental rights.2 Even anti-TGD legislation not directly impacting GAC adversely impacts TGD youth and their families, for example by restricting gender expression or pronoun and name use in school settings, or otherwise creating a more hostile community environment that compounds psychological stress and is associated with higher rates of anxiety, depression, and suicidal thoughts seen among TGD youth.11 Especially in states where legislation directly targets GAC, HCW worry about losing licensure or incurring lawsuits.12 Oftentimes, policy language evolves quickly throughout a legislative session or may remain intentionally vague.
Organizational support is necessary for staff to remain up to date on proposed legislation impacting HCW, patients, and families, to equip HCW to understand consequences for clinical practice, manage risk, and provide expert testimony. Ideally, dedicated legal support within a health care organization, or a medical-legal partnership, would help guide departments and clinicians. This may be especially challenging, however, for smaller community-based health centers with limited resources. Utilizing extant resources like the Trans Legislation Tracker can be helpful.1 It is of utmost importance for HCW and institutions to connect with LGBTQIA+ (lesbian, gay, bisexual, transgender, /queer, intersex, asexual) community and legal organizations to collaboratively defend against such legislation, advocate for meaningful legal protections, and safeguard GAC for TGD people.
Combating Misinformation and Disinformation
Anti-transgender legislation has thrived in a media environment of misinformation and disinformation. False and misleading claims about gender diversity, gender dysphoria, and GAC have been central to proposed legislative restrictions on GAC,13 in both the USA and globally, as with the UK’s Cass Review and the National Health Service’s decision to limit use of pubertal blockers in context of GAC.14 Restrictions on GAC have been justified by depicting GAC as experimental or unsafe, ignoring studies that show positive outcomes in youth with use of puberty blockers and exogenous hormones, and overstating risks such as thromboembolism.3 Advocates for restrictions also make false statements about what constitutes standards of care for GAC, by claiming that medical interventions such as gender-affirming hormones are provided to pre-pubertal children, and that gender-affirming surgeries are easily accessible by and common among adolescents.3
In addition to legislative attacks, physical attacks against HCW and hospitals occur based on such false information: for example, Boston Children’s Hospital received bomb threats based on disinformation regarding its conduct of gender-affirming surgeries on children.15 False information about GAC can harm TGD youth and families, HCW, health educators, hospital administrators, and policymakers.
Community-focused outreach, engagement, and education are critical public-facing functions for all health care organizations providing GAC. This may take the form of patient education materials, support groups, Q&A sessions, tabling at community events, and partnering with LGBTQIA+ community organizations. Media coverage is an important aspect of this work. Health care organizations should provide appropriate media training for clinicians who wish to interface with the media, and institutional media relations departments should work closely with clinicians to providing accurate information and proper context for trustworthy local and national news outlets. Organizations may utilize the existing framework of rapid-response rebuttal reports written by interdisciplinary, multi-institutional teams of both medical and legal professionals.13,16 Organizations can help counter widely cited and harmful arguments supporting GAC bans, such as claims in the Cass Review, by disseminating statements from major medical associations like the Endocrine Society17 and the Integrity Project’s carefully crafted response.14
Safety and Security
In 2022, the Human Rights Campaign (HRC) Foundation identified 24 hospitals and HCW targeted by harassment campaigns, mostly originating from social media accounts dedicated to spreading anti-LGBTQIA+ disinformation and inflammatory rhetoric.15 HCW have received death threats,18 had their personal phone numbers, work, and home addresses leaked (“doxing”), and faced both online and offline harassment.15,19 Targeted health centers and hospitals received numerous threatening calls, emails, and in-person protests.11 These harassment campaigns have prompted GAC clinical website shutdowns, cessation of care services, shifting of in-person appointments to telehealth, and complete closure of clinics.15
Such threats significantly impede provision of GAC, and of all medical care, as they lead to increased spending on security, and in extreme cases, complete lockdowns.15 Individual HCW can ensure their own private information is less accessible online through various fee-based services. Tailored clinic-level decisions can determine the extent of public-facing information about care services and specific staff. Organizational support is crucial for HCW who provide GAC, including investment in necessary in-person security and cybersecurity.
Police surveillance and violence disproportionately impact TGD people, particularly TGD people of color.20,21 Coordination with the police and state law enforcement, and increased security measures on site, when necessary, should occur with a trauma-informed approach that is mindful of the well-being of marginalized community members among both patients and staff. Diverse local community voices are vital for guiding these decisions.
Conclusion
If health care organizations such as federally qualified health centers offer or want to begin offering GAC, they must create safe environments for patients, families, and HCW who strive tirelessly to deliver care. In the current sociopolitical environment, it is no longer sufficient to merely issue general statements in support of Diversity, Equity and Inclusion. Health care organizations must demonstrate their commitment with material resources that ensure continued and expanding access to GAC, address health injustices, fund advocacy for legislative protections, enable public education, and create safe and welcoming clinical spaces for patients and HCW. These substantive organizational actions are not accessory to providing GAC but rather essential for its sustainment.
References
Tracking the rise of anti-trans bills in the US: Trans Legislation Tracker; 2023 [Available from: https://translegislation.com/learn. Accessed 1 Feb 2024.
Redfield E, Conron KJ, Tentindo W, Browning E. Prohibiting Gender-Affirming Medical Care for Youth. Los Angeles, CA: UCLA; 2023.
McNamara M, McLamore Q, Meade N, Olgun M, Robinson H, Alstott A. A thematic analysis of disinformation in gender-affirming healthcare bans in the United States. Soc Sci Med. 2024; 351: 116943.
LGBTQ Policy Spotlight: Bans on Medical Care for Transgender People. Movement Advancement Project; 2023 April 15 2023.
D’Hoore L, T’Sjoen G. Gender-affirming hormone therapy: An updated literature review with an eye on the future. J Intern Med. 2022; 291(5): 574-92.
Swan J, Phillips TM, Sanders T, Mullens AB, Debattista J, Brömdal A. Mental health and quality of life outcomes of gender-affirming surgery: A systematic literature review. J Gay Lesbian Mental Health. 2023; 27(1): 2-45.
Carpenter CS, Eppink ST, Gonzales G. Transgender Status, Gender Identity, and Socioeconomic Outcomes in the United States. ILR Review. 2020; 73(3): 573-99.
Hidalgo MA, Chen D. Experiences of gender minority stress in cisgender parents of transgender/gender-expansive prepubertal children: A qualitative study. J Fam Issues. 2019; 40(7): 865-86.
Aramburu Alegría C. Supporting families of transgender children/youth: Parents speak on their experiences, identity, and views. Int J Transgend. 2018; 19(2): 132-43.
Abreu RL, Sostre JP, Gonzalez KA, Lockett GM, Matsuno E, Mosley DV. Impact of gender-affirming care bans on transgender and gender diverse youth: Parental figures’ perspective. J Fam Psychol. 2022; 36(5): 643-52.
Gosling H, Pratt D, Montgomery H, Lea J. The relationship between minority stress factors and suicidal ideation and behaviours amongst transgender and gender non-conforming adults: A systematic review. J Affect Disord. 2022; 303: 31-51.
Hughes LD, Kidd KM, Gamarel KE, Operario D, Dowshen N. “These Laws Will Be Devastating”: Provider perspectives on legislation banning gender-affirming care for transgender adolescents. J Adolesc Health. 2021; 69(6): 976-82.
McNamara M, Abdul-Latif H, Boulware SD, Kamody R, Kuper LE, Olezeski CL, et al. Combating scientific disinformation on gender-affirming care. Pediatrics. 2023; 152(3).
McNamara M, Baker KE, Connelly K, Janssen A, Olson-Kennedy J, Pang KC, et al. An Evidence-Based Critique of “The Cass Review” On Gender-affirming Care for Adolescent Gender Dysphoria The Integrity Projectcass; 2024.
Online Harassment, Offline Violence: Unchecked Harassment of Gender-Affirming Care Providers and Children’s Hospitals on Social Media, and its Offline Violent Consequences. Human Rights Campaign; 2022.
McNamara M, Lepore C, Alstott A. Protecting transgender health and challenging science denialism in policy. New England J Med. 2022; 387(21): 1919-21.
Endocrine Society Statement in Support of Gender-Affirming Care [press release]. Washington, DC: Endocrine Society2024.
Keuroghlian AS. Countering the health disinformation machine. N Engl J Med. 2023; 389(14): 1256-8.
Hughes LD, Gamarel KE, Restar AJ, Sequeira GM, Dowshen N, Regan K, et al. Adolescent providers’ experiences of harassment related to delivering gender-affirming care. J Adolesc Health. 2023; 73(4): 672-8.
Sternersen MR, Thomas K, McKee S. Police and transgender and gender diverse people in the United States: A brief note on interaction, Harassment, and violence. J Interperson Viol. 2022; 37(23-24): NP23527-40.
Thompson HM, Wang TM, Talan AJ, Baker KE, Restar AJ. First they came for us all: Responding to anti-transgender structural violence with collective, Community-Engaged, and intersectional health equity research and advocacy. Health Educ Behav. 2024; 51(1): 5-9.
Topic
JGIM
Author Descriptions
Harvard Medical School, Boston, MA, USA
Hyun-Hee Kim MD, Nova Thayer BA, Caryn Bernstein MPH & Alex S. Keuroghlian MD, MPH
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
Hyun-Hee Kim MD & Alex S. Keuroghlian MD, MPH
Texas Association of Community Health Centers, Austin, TX, USA
Roxana Cruz MD
Community Health Center Association of Mississippi, Jackson, MS, USA
Christopher Roby PhD
The Fenway Institute, Fenway Health, Boston, MA, USA
Alex S. Keuroghlian MD, MPH
Massachusetts General Hospital, Yawkey Building, Suite 6A, 55 Fruit Street, Boston, MA, 02114, USA
Hyun-Hee Kim MD
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