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Attacks on Gender-Affirming and Transgender Health Care

Published: 8/6/24

A growing number of states are banning gender-affirming health care and pursuing anti-LGBTQ+ legislation, contrary to ACP policy, which urges non-discrimination in health care.  ACP opposes these restrictions on health care for transgender individuals, who already may face extreme barriers to accessing care, and strongly objects to government interference with evidence-based health care services.

Background

In 2021, Arkansas became the first state in the country to ban gender-affirming health care for transgender minors. Since then, have restricted gender-affirming services for minors and/or adults.  These bans are typically enforced by criminal, civil, and professional penalties for clinicians who provide services, as well as sometimes penalties for parents of children who support their children's access to essential health care.   The recent trend to restrict gender-affirming care is part of an overall proliferation of anti-LGBTQ+ legislation at the state level, with introduced so far in 2024.

The Office of Population Affairs at the U.S. Department of Health and Human Services (HHS) defines as “an array of services that may include medical, surgical, mental health, and non-medical services for transgender and nonbinary people. For transgender and nonbinary children and adolescents, early gender-affirming care is crucial to overall health and well-being as it allows the child or adolescent to focus on social transitions and can increase their confidence while navigating the healthcare system.” Gender-affirming care is evidence-based medicine by many medical organizations, and after shows that gender-affirming care reduces depression and suicide among transgender youth. ACP and other leading medical organizations have condemned efforts to criminalize gender-affirming care and other evidence-based care as interference with the physician-patient relationship.

While restrictions initially focused on preventing minors from accessing gender-affirming care, states have increasingly transgender health care for adults, with several states proposing bans through age 26 or restricting care for patients of all ages.  Multiple states have also sought to limit both public and private insurance coverage of gender-affirming care, endangering access to essential care for transgender individuals of all ages. The Williams Institute at the UCLA School of Law that 237,500 transgender youths ages 13-17 live in states that have already banned gender-affirming care or where such a law has been proposed in 2024, with approximately 114,000 of these young people living in states that have already enacted ban.  In multiple states, these bans have forced transgender youth to medically detransition and stop successful gender-affirming treatments.  With patients facing loss of medical care and their families and clinicians under legal threat, some transgender people and their families who can relocate have , or are trying to navigate traveling out of state for routine care.  Beyond immediate impacts, these laws drive stigma and endanger the wellbeing of LGBTQ+ people.  According to the Trevor Project’s , one in three LGBTQ+ young people reported that their mental health is poor most of the time or always because of anti-LGBTQ policies and legislation.

In June 2024, ACP published a new position paper on , which reaffirmed the College’s commitment to promoting equitable access to quality care for all people regardless of their sexual orientation and gender identity.  This paper recognized the pressing need for physicians and other health professionals to take a stance against discriminatory policies proliferating at the federal and state levels, particularly the imposition of medically unnecessary restrictions on gender-affirming care.  ACP is committed to challenging political interference in the patient-physician relationship, including by strongly supporting access to evidence-based, clinically-indicated gender-affirming care.

Federal Activity

While the majority of activity is taking place on the state level, federal policymakers have also taken action as part of this legislative trend.  proposes a national ban on gender-affirming care for minors, and other legislation would implement additional restrictions around education that have been introduced at the state level.  Other restrictive proposals have included funding for members of the military or their families to seek gender-affirming care.  Opponents of these restrictions have introduced measures including /, which would establish a transgender bill of rights under the Civil Rights Act to protect access to medical care and other essential services.

In April 2024, the Biden administration finalized a rule revising the interpretation of the Affordable Care Act’s anti-discrimination provision, Section 1557, to prohibit discrimination on the basis of gender identity and sexual orientation as part of the ban on sex-based discrimination.  ACP had provided comments in support of the rule after its proposal and applauded the rule’s finalization.  However, in July 2024, a federal judge blocked this rule from going into effect and ordered a nationwide injunction, halting its enforcement while legal challenges proceed.

In June 2024, the Supreme Court agreed to hear a case in its 2024-2025 term regarding Tennessee law banning access to puberty blockers and hormone therapy for transgender minors.  ACP will be monitoring this case that has the potential to significantly impact access to gender-affirming care across the country, with oral arguments expected in fall 2024 and a decision likely sometime in spring 2025.

State Activity

Among the more than 500 anti-LGBTQ+ bills introduced in state legislatures in 2024, at least 112 of those bills have proposed restrictions in at least 40 states on gender-affirming care or transgender health care.  While most restrictions have been legislative, some states have used administrative means to restrict access to gender-affirming care.  In Texas, Governor Greg Abbott the Department of Family and Protective Services to investigate parents with transgender children for abuse for helping their children obtain this evidence-based care, threatening custody removal and criminal penalties.  In Florida, the state’s Agency for Health Care Administration Medicaid coverage for gender-affirming services for transgender patients of any age and the Board of Medicine and Board of Osteopathic Medicine passed restricting gender-affirming care for minors at the encouragement of Governor Ron DeSantis.  These rules, as well as a subsequently passed state law with similar provisions, remain by a federal judge for the three minors whose families brought a legal challenge. 

Among the at least 26 states that have enacted bans on gender-affirming care, at least face lawsuits challenging restrictions.  Since 2023, ACP has joined amicus briefs in at least 14 cases challenging state laws restrictions access to or coverage of gender-affirming care.  In these cases and others, the Supreme Court’s decision in the Tennessee case it has taken for its next term will likely be determinative of the final outcome.

In response to the rise in restrictions, a number of states have taken actions to protect access to gender affirming care.  At least 14 states have enacted “shield laws” to protect patients and clinicians from penalties associated with obtaining or providing gender-affirming care in their states, with governors in two additional states implementing executive orders along similar lines.  Many of these laws also include protections for reproductive health services as abortion care has been criminalized following the overturn of Roe v. Wade or are being considered alongside similar bills amidst increasing criminalization of evidence-based care in the states.  In total, have prohibited insurance from excluding transgender health care services from coverage.

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