Care Under Attack: The Politicization of Pediatric and Adolescent Gender-Affirming Care and Ways Forward

Landon Hughes, PhD(c); Arjee Restar, PhD, MPH; Kristi Gamarel, PhD, EdM; Kacie Kidd, MD, MS; Nadia Dowshen, MD, MSHP; & the HIV and Sexual Health SIG

In the United States, concerted efforts from anti-trans legislators in nearly half of the states introduced bills or passed legislation that criminalizes the provision of gender-affirming care to transgender minors¹, a political tactic that established medical organizations have ubiquitously condemned.^2–4 In 2022 alone, more than 155 bills related to trans people and their health have been introduced – a comparable amount to 19 bills in 2018.⁵ Arkansas⁶ was the first to pass such a law, which the U.S. District Court is currently staying as the Court determines whether the law violates the Fourteenth Amendment's equal protection and due process clauses or providers' First Amendment rights.⁷  Some states have used executive orders or appointments to intimidate families from accessing care. For example, Texas Governor Greg Abbott directed the Department of Family and Protective Services to investigate and charge families who allow their children to access gender-affirming care with child abuse; however, this action was later stayed by the courts.⁸

Despite legal stays, these political efforts have also been initiated and sustained by anti-trans groups such as Gender Critical and the Alliance Defending Freedom, and have affected adolescents, families, and their providers. Specifically, acts of terror against providers such as harassment and threats, including bomb threats,⁹ death threats,¹⁰ clinic protests,¹¹ and political pressure, have been documented, causing some providers to have their clinics shuttered.¹² Parents and providers of transgender adolescents have reported that restrictions on gender-affirming care will likely increase depression, anxiety, and suicidal ideation since the benefits of such intervention alleviate these conditions.^13,14 Parents describe willingness to uproot their livelihood and move to more protected states to avoid these laws, despite financial and personal costs, leaving those who are less affluent to face political injustice.¹³ Moreover, given that transgender adolescents already face barriers to accessing gender-affirming care, such as provider mistrust, stigma, and a lack of affirming familial or social environments on a day-to-day basis,^15–17 these political punishments and restrictions only add to existing obstacles in health care and have direct impact to further exacerbate racial inequities in access to pediatric gender-affirming care.¹⁸

Ensuring Access to Gender-Affirming Care

Ensuring access to gender-affirming care is critical to the lives and well-being of transgender adolescents, especially in times when such provisions are being threatened in social, medical, and political arenas. There are several ways we can work to ensure access. First, individuals can provide financial or expert support to those challenging these laws in court. This may include donating to organizations, such as the American Civil Liberties Union, that are leading challenges in court or serving as an expert witness or plaintiff in cases. Second, individuals can lobby legislators and advocate for laws that protect the rights of transgender adolescents to access gender-affirming care. This may include contacting legislators, writing letters, or participating in campaigns. Third, individuals can help providers through instrumental support (e.g., funding for increased safety measures in their clinic) to ensure they are able to see patients. Fourth, providers and parents implore more effort on behalf of major medical associations to educate the public about the benefits of gender-affirming care and train more providers to deliver high-quality care.^13,14,19 Fifth, it is critical for states’ healthcare systems to continue in their efforts to provide gender-affirming care, particularly among states and hospital systems that receive federal support such as Medicare and Medicaid, given the current federal approval of gender-affirming care as an essential health benefit benchmark plan.²⁰ Lastly, individuals can support transgender adolescents and their families by donating to funds that help families afford the costs associated with gender-affirming care²¹ and connecting them to existing resources such as TransFamily Support Services²², which help families navigate barriers to accessing care.

Conclusion

Transgender adolescents and their families deserve access to high-quality, evidence-based gender-affirming care. Efforts to limit or ban this care not only have significant negative impacts among providers’ physical safety but also directly terrorize the well-being of adolescents, families, particularly those who are already facing other forms of systemic inequities. We have a responsibility as medical organizations, providers, parents, and allies to condemn anti-trans legislation as well as acts of transphobia, and work to protect and expand this critically important care.

References:

 1.        Freedom For All Americans. Legislative Tracker: Anti-Transgender Medical Care Bans. Freedom For All Americans. Published January 26, 2023. Accessed December 22, 2021. https://freedomforallamericans.org/legislative-tracker/medical-care-bans/

2.         Rafferty J, Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence, Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018;142(4):e20182162. doi:10.1542/peds.2018-2162

3.         Lopez X, Marinkovic M, Eimicke T, Rosenthal SM, Olshan JS. Statement on gender-affirmative approach to care from the pediatric endocrine society special interest group on transgender health. Curr Opin Pediatr. 2017;29(4):475-480. doi:10.1097/MOP.0000000000000516

4.         American Psychiatric Association. Frontline Physicians Oppose Legislation That Interferes in or Criminalizes Patient Care. Published April 2, 2021. Accessed December 22, 2022. https://www.psychiatry.org/newsroom/news-releases/frontline-physicians-oppose-legislation-that-interferes-in-or-criminalizes-patient-care

5.         Branigin A, Kirkpatrick N. Anti-Trans Laws Are on the Rise. Here’s a Look at Where — and What Kind. Washington Post. https://www.washingtonpost.com/lifestyle/2022/10/14/anti-trans-bills/. Published October 14, 2022. Accessed January 9, 2023.

6.         TO CREATE THE ARKANSAS SAVE ADOLESCENTS FROM EXPERIMENTATION (SAFE) ACT. Vol HB 1570.

7.         Cathey L. Judge blocks Arkansas law banning health care for transgender youth. ABC News. https://abcnews.go.com/Politics/judge-blocks-arkansas-law-banning-health-care-transgender/story?id=78954056. Published July 21, 2021. Accessed December 22, 2022.

8.         Perez J. Texas judge halts Abbott’s transgender investigation order. Politico. https://www.politico.com/news/2022/03/11/texas-judge-abbott-transgender-investigation-order-00016802. Published March 11, 2022. Accessed December 22, 2022.

9.         Moghe S. Woman faces federal charge for calling in a false bomb threat to a Boston hospital providing gender-affirming care. CNN. https://www.cnn.com/2022/09/15/us/boston-hospital-bomb-threat-gender-affirming-care/index.html. Published September 16, 2022. Accessed December 22, 2022.

10.       Sands L. Man charged with threatening doctor caring for trans patients, LGBTQ kids. The Washington Post. https://www.washingtonpost.com/nation/2022/12/04/lgbtq-children-boston-doctor-threats/. Published December 4, 2022. Accessed December 22, 2022.

11.       Gluck F, Friedman A, Shoup C. GOP legislative leaders say they’ll introduce ban to end gender-affirming care for minors in Tennessee. The Tennessean. https://www.tennessean.com/story/news/2022/10/21/nashville-protest-rally-gender-affirming-care-minors-tennessee-capitol/69579695007/. Published October 21, 2022. Accessed December 22, 2022.

12.       Rummler O. Political pressure led to shutdown of Texas’ largest gender-affirming care program. The Texas Tribune. https://www.texastribune.org/2022/03/11/texas-genecis-closure-transgender/. Published April 11, 2022. Accessed December 22, 2022.

13.       Kidd KM, Sequeira GM, Paglisotti T, et al. “This Could Mean Death for My Child”: Parent Perspectives on Laws Banning Gender-Affirming Care for Transgender Adolescents. J Adolesc Health. Published online October 2020:S1054139X20305267. doi:10.1016/j.jadohealth.2020.09.010

14.       Hughes L, 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):976-982. doi:10.1016/j.jadohealth.2021.08.020

15.       Gridley SJ, Crouch JM, Evans Y, et al. Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth. J Adolesc Health. 2016;59(3):254-261. doi:10.1016/j.jadohealth.2016.03.017

16.       Pampati S, Andrzejewski J, Steiner RJ, et al. “We deserve care and we deserve competent care”: Qualitative perspectives on health care from transgender youth in the Southeast United States. J Pediatr Nurs. 2021;56:54-59. doi:10.1016/j.pedn.2020.09.021

17.       Eisenberg ME, McMorris BJ, Rider GN, Gower AL, Coleman E. “It’s kind of hard to go to the doctor’s office if you’re hated there.” A call for gender‐affirming care from transgender and gender diverse adolescents in the United States. Health Soc Care Community. 2020;28(3):1082-1089. doi:10.1111/hsc.12941

18.       Goldenberg T, Jadwin-Cakmak L, Popoff E, Reisner SL, Campbell BA, Harper GW. Stigma, Gender Affirmation, and Primary Healthcare Use Among Black Transgender Youth. J Adolesc Health. 2019;65(4):483-490. doi:10.1016/j.jadohealth.2019.04.029

19.       McNamara M, Lepore C, Alstott A, et al. Scientific Misinformation and Gender Affirming Care: Tools for Providers on the Front Lines. J Adolesc Health. 2022;71(3):251-253. doi:10.1016/j.jadohealth.2022.06.008

20.       The White House. FACT SHEET: Biden-⁠Harris Administration Advances Equality and Visibility for Transgender Americans. Published online March 21, 2022. Accessed January 9, 2023. https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/31/fact-sheet-biden-harris-administration-advances-equality-and-visibility-for-transgender-americans/

21.       Campaign for Southern Equality. Trans in the South: Funding Your Transition. Published January 2, 2023. Accessed January 2, 2023. https://southernequality.org/resources/transinthesouth/funding-your-transition/

22.       TransFamily Support Services. TransFamily Support Services. Published January 2, 2023. Accessed January 2, 2023. https://transfamilysos.org