In state after state, doors are quickly slamming shut on the ability of doctors to provide gender-affirming care for transgender minors.
The newest restriction is set to take effect Thursday in Florida, where that state's Board of Medicine decided last month to ban the use of all puberty blockers, hormone therapies and/or surgeries for any patient under 18, whether or not those minors have parental approval for such care.
The ban stems from an effort first launched by Gov. Ron DeSantis and the Florida Surgeon General back in April 2022, when the pair issued a joint call for the ban. That was followed in August 2022 by the Florida Agency for Health Care Administration's rewriting of Medicaid coverage rules that disallowed reimbursements for any gender-affirming treatments involving both minors and adults.
Minors who were already receiving puberty blockers before the new ban may continue taking them. Otherwise, the ban is complete: Florida transgender minors are no longer allowed access to gender-affirming medical care, even in a clinical trial.
As a board ruling — rather than a new state law — Florida doctors who violate the ban will not face criminal charges, though they will be subject to censure, fines and the potential loss of their right to practice medicine in the state. Last week, Republican state lawmakers tabled a bill that would have gone a step further by passing a law that would have prohibited all treatments for gender-affirming care involving minors.
“It is very clear that this is part of a full-on national assault against the transgender community,” said Nikole Parker, the Orlando-based director of transgender equality with Equality Florida.
“Here in Florida, we're trying to mitigate the harm as much as possible, and give as much support to the community as we can,” Parker noted. “But this is clearly happening all across the U.S.”
'Pay attention' to kids
Indeed, Florida is hardly alone. In 2021, Arkansas became the first to legislate a ban on some or all of the same procedures. It was followed in short order by five more: Alabama, Utah, Mississippi, South Dakota and Tennessee.
Not all of the bans have taken effect, pending legal wrangling. But dozens of other states are now sifting through a total of 85 legislative proposals — up from just 43 in 2022 and 32 in 2021 — aimed at sharply curtailing or eliminating all medical treatments for hundreds of thousands of American teens who identify as transgender.
Why is this happening? What is gender-affirming medical treatment for minors in the first place? Is it safe? And is the movement to ban access truly about protecting children?
“First of all, when a child tells you how they want to wear their hair, you should pay attention,” said Kellan Baker, a transgender health care policy expert and executive director of the Whitman-Walker Institute, in Washington, D.C. “When they tell you how they want to dress, you should listen. And when a child tells you who they are, you should believe them."
He explained that such youthful statements — whether expressed verbally or physically — can point to a deep disconnect between a child's assigned gender at birth versus the gender with which they actually identify.
It's a disconnect that can come with profound mental health consequences: A research letter published last July in JAMA Network Open found transgender children as young as 9 and 10 face a notably higher risk for anxiety, poor sleep and depression, when compared with their non-transgender peers.
When those expressions of transgender identity come early — before adolescence — gender-affirming treatment involving medicines or surgery is not even an option.
“No [medical] protocols allow for medicinal intervention before puberty,” confirmed Dr. Meredithe McNamara, an adolescent medicine specialist with Yale University's School of Medicine. That means no puberty blockers, no hormones, no surgery.
Most forgo medical options
When America's transgender youth hit puberty, however, a whole new set of challenges arise, Baker noted, “because what's happening then are irreversible physical changes that can cause anxiety, depression, suicidation [suicidal thoughts] and gender dysphoria [a severe form of psychological distress rooted in a gender mismatch]."
“These kids know the ways in which their body will start to change,” he stressed. “And they know it's wrong for who they are.” And that, he said, is where medical gender-affirming care can come into play.
The broad pool of American teens who might need or benefit from gender-affirming care ranges from about 150,000 (according to the American Academy of Pediatrics) to about 300,000 (according to the University of California, Los Angeles' Williams Institute).
But in truth, the vast majority of transgender teens do not actually feel they need or want such care, said McNamara, who has testified on the experience of transgender youth before the Florida Board of Medicine.
“It's important to point out that really very few get anywhere near gender-affirming health care or consultation,” she said. “Really, the most common intervention is affirmation, validation and support, not medicine.”
Still, for those who do need more care, puberty blockers are a longstanding option.
First approved by the U.S. Food and Drug Administration in 1993, “puberty-blocking medication is a way to stall physical change associated with the production of endogenous [natural] sex hormones,” explained McNamara.
“And while in use, a pubertal teen is not going to experience any physical change,” she noted. “No body hair growth, no breast development, no semen production. Those things aren't going to happen for a period of time.”
McNamara noted puberty blockers are a “great way and a compassionate way” to give trans youth the time and space to get psychological help so they can better cope with their transition.
Baker added, “All it does is hit pause on puberty, so the young person has more time to make decisions, to figure out who they are and what they need. Typically you can take it up to three years, but it's guided by experts and it's reversible.”
According to U.S Department of Health and Human Services (HHS), other gender-affirming medical options include hormone therapy — in which testosterone or estrogen is prescribed — and surgery. The latter (potentially involving breast reduction or enhancement and/or “bottom” surgery in the genital area) is exceedingly rare among adolescents.
Risks and benefits
The HHS states that all of the interventions help “lower rates of adverse mental health outcomes, build self-esteem and improve overall quality of life for transgender and gender-diverse youth.”
Both Baker and McNamara acknowledged that some medical options carry potential side effects that need to be carefully monitored. The impact that puberty blockers can have on bone density growth is one such concern, given that puberty is a time of dramatic bone growth.
“But the evidence does show that density recovers to pre-treatment levels once medication is stopped,” noted McNamara, and “we have no evidence to show that the blockers lead to fractures” or worse bone health down the road.
“I would also point out that parents who have consented to the use of puberty blockers for their trans youth are not going to be suddenly shocked to hear about bone density concerns in the news. This is not some deep dark secret," she added. "This is precisely the kind of thing that is being discussed in privately held conversations between doctors, parents and patients before any steps are taken, just as it should be.”
One renowned Florida-based pediatric endocrinologist who specializes in gender-affirming care seconded the thought, adding that states have no business getting involved in such an “incredibly thoughtful and serious undertaking.”
“Like any medical therapeutic, there are risks and benefits with gender-affirming care that have to be discussed with patients and families, and that's happening,” said the endocrinologist, who wanted to remain anonymous in order to speak freely.
“But the larger point is that the health care that's being offered to transgender youth is not being dispensed on a drive-through basis," the endocrinologist added. "That's a total misconception. This isn't treatment on a whim. We aren't just giving puberty blockers or hormones out just like that.”
In fact, so slow and rigorous is the typical assessment process that it can take between 6 and 12 months before a patient gets any medical treatment at all, said McNamara.
So the upshot, said Baker, is simple: For years, all across the country, the gender-affirming health care community has been dispensing high-quality, safe care to a vulnerable population in real need.
“That's all that's happening,” he stressed. “People are now claiming that this is controversial. It's not controversial. It is a settled medical consensus.”
Nearly all major U.S. medical associations — including the American Academy of Pediatrics (AAP), the American Medical Association and the Children's Hospital Association — have all endorsed gender-affirming care for minors.
Last September, the AAP directly addressed the debate, stating that it “strongly oppose[s] any legislation or regulation that would discriminate against gender-diverse individuals, including children and adolescents, or limit access to comprehensive evidence-based care, which includes the provision of gender-affirming care.”
So, what explains the heated battle to ban access to gender-affirming medical care?
A recent Pew Research Center survey offers a clue: The survey of more than 10,000 adults cited broad support (64%) for protecting transgender people against discriminatory housing or employment practices. At the same time, it found that 46% of respondents were in favor of making it illegal for health care professionals to provide minors with gender-affirming care.
Many in the transgender community believe numbers like that go a long way towards explaining what appears to be a play for votes, rather than true concern over the health care of transgender minors.
“This is about politics,” said Parker. “The trans community is just trying to access health care like everybody else. But it's very clear that politicians have chosen this as a wedge issue because they know the trans experience is poorly understood by the public.”
McNamara said parents reading about what's going on with transgender health care should ask themselves a simple question: How they would feel if someone stepped in and took away their ability to make health decisions for their kids?
“What kind of grace and space and privacy would they want,” she asked.
There's more on gender-affirming care at the U.S. Office of Population Affairs.
SOURCES: Nikole Parker, director, transgender equality, Equality Florida, Orlando; Kellan Baker, PhD, MPH, transgender health care policy expert, Whitman-Walker Institute, Washington, D.C.; Meredithe McNamara, MD, adolescent medicine specialist, Yale University School of Medicine, New Haven, Conn.