Sean Woolley, 15, right, and his mother Ashley Moore, hold hands as they attend a protest of transgender youth, their families and supporters at the Mississippi Capitol in Jackson, Wednesday, Feb. 15, 2023. The group protested House Bill 1125, which would ban gender-affirming care for trans children. (AP Photo/Rogelio V. Solis)
In some states, new laws banning gender-affirming care for transgender youth are dissuading health care providers from offering mental health services and other medical care that isn’t explicitly banned by those laws.
In the first few weeks after Mississippi’s law went into effect in February, nurse practitioner Stacie Pace said she was fielding calls and emails from parents of trans youth who said their children’s pediatricians would no longer see them for routine care. Pace offers gender-affirming care at a clinic in Hattiesburg.
“[Parents] weren’t able to bring their kids to the pediatrician they were seeing before because the ban scared the pediatrician,” said Pace. She said the vague language in Mississippi’s law scared primary, mental health and other providers from seeing trans youth and even adults. One parent told her their child needed a refill on asthma medication and their doctor refused to see them.
In Texas, a new law banning gender-affirming care for minors is pushing some providers, including the pediatrician who led a program that offered mental health services and hormone treatments to transgender children, to leave the state. Dr. Ximena Lopez, a pediatric endocrinologist, has said publicly she is leaving Texas out of concern for the safety of herself and her family.
And in Arizona and Missouri, advocates worry that new state laws barring medical practitioners from referring transgender youth to other providers for “gender transition procedures” might curb access to counseling and therapy.
The new laws do not focus on mental health services. In fact, some state lawmakers who have sponsored bans on surgery or hormone therapy have stressed their support for mental health care.
Indiana state Rep. Michelle Davis, a Republican who sponsored Indiana’s new law prohibiting gender-affirming care for minors, told Stateline earlier this year: “We should continue to support children who may be struggling by ensuring they have access to compassionate mental health care.”
But state bans on services such as hormone therapies and surgery can create a climate of fear and confusion for trans youth, families and care providers that can have a chilling effect on all types of care, said Elana Redfield, federal policy director at UCLA School of Law’s Williams Institute, a public policy think tank focused on sexual orientation and gender identity issues.
“If you’re a young person who is trans or a parent of that young person, you might feel concerned about asking for any kind of care for fear it might come back to hurt you or your family,” Redfield said.
Heather Stone, a licensed counselor in Huntsville, Alabama, who sees trans patients, saw that chilling effect after Alabama passed its law last year, even though a court order is currently preventing it from taking effect.
“Mental health treatment for trans youth is not illegal in Alabama,” said Stone, “but the law is so vague that it makes parents and children more hesitant to even seek mental health treatment because they’re confused whether” that treatment has been banned.
Across the country, legislators in at least 21 Republican-led states have passed laws banning or restricting gender-affirming care for minors, according to the Movement Advancement Project, a nonprofit think tank that tracks LGBTQ+ state policies. Similar laws have been considered in at least seven other states this year.
The raft of new legislation is part of a recent nationwide effort by GOP-led state legislatures to place new restrictions on transgender people. Multiple states have enacted laws that bar transgender girls from competing on girls sports teams, prohibit discussions of gender identity in classrooms and outlaw drag shows when minors are present.
The laws restricting gender-affirming health care vary by state, but mainly prohibit hormone therapy and gender-affirming surgery for transgender minors. Implementation has been patchy, as many of the laws face court challenges and some aren’t scheduled to go into effect until later this year.
Legislators sponsoring the bills have cited a lack of information on the long-term effects of hormone therapy on adolescents. Republican state Rep. Jim Olsen of Oklahoma, who voted for his state’s law banning gender-affirming care, said that he hoped to spare teens from undergoing “irreversible procedures” they might later regret.
“Even one child who undergoes a life-altering procedure and later laments their decision is one too many,” Olsen said.
The U.S. Department of Health and Human Services describes gender-affirming care as a spectrum of medical and non-medical services that can include social affirmation, hormone therapy, mental health services and surgery.
Gender-affirming surgery is rarely performed on patients under 18. Puberty-blocking drugs and hormone treatments are prescribed by physicians to some children and adolescents struggling with gender dysphoria, a condition in which a person’s gender identity doesn’t align with their sex assigned at birth.
Major U.S. medical organizations — including the American Medical Association, the American Academy of Pediatrics and the American Psychiatric Association — oppose bans on gender-affirming care and support care for minors when administered appropriately.
These are people who deserve to have their basic health care needs met, just like anyone else.
– Stacie Pace, nurse practitioner in Hattiesburg, Mississippi
However, some European countries, including Norway and the United Kingdom, recently changed or have considered changing medical guidelines on gender-affirming care for minors. Data analyzed by public health officials in England, Finland and Sweden found long-term studies failed to show improvements in mental health and suggested puberty blockers could hinder bone development.
A ‘chilling effect’
Johnathan Gooch of Equality Texas, a statewide organization that advocates for LGBTQ+ rights, said rhetoric and legislation from Texas lawmakers on transgender issues already have eroded health care options for both trans youth and adults.
“Because we’ve seen such a sustained attack on trans youth, there are a lot of trans-focused health providers that have closed up shop over time,” he said, citing the closure of gender-affirming services for adolescents at Texas Children’s Hospital in Houston. “The options have been consistently narrowing since February 2022.”
That’s when Texas Republican Gov. Greg Abbott directed the Texas Department of Family and Protective Services to investigate reports of children undergoing gender-affirming care as potential child abuse. Gooch said some mental health providers at the time were concerned that they’d be required as mandatory reporters to turn in parents who brought their children in for mental health visits related to gender-affirming care.
“We did see a chilling effect among mental health providers, who would prefer to end their client relationship rather than being forced to report them to authorities, even though that was a misunderstanding of the law.”
Stone, the licensed counselor in Alabama, said she knows providers who are afraid to treat trans youth and adults since the state law passed last year.
“We have to ask [ourselves], am I providing gender-affirming care, and is that illegal?” she said. “My reading of it, and I’m not an attorney, is that supportive mental health is not illegal. But you never know. But I’m not going to stop providing it at this point because I think that would be ethically wrong and there’s a huge need in the community.”
Oliver Hall is the trans health director at the Kentucky Health Justice Network, which connects trans clients with gender-affirming health resources and provides guidance on insurance coverage. A federal judge recently lifted an injunction on Kentucky’s ban on gender-affirming care for trans youth, allowing it to take effect.
“There is a lot of misunderstanding about what the law does with regard to mental health care,” Hall said in a statement to Stateline. While the current law does not ban mental health services, a different bill, which did not pass, would have explicitly banned gender-affirming mental health care for minors.
“This has also obviously added to the chilling effect for mental health care providers treating trans youth,” Hall said.
Issues with affordability
Some states, including Arizona, Arkansas, Mississippi and Missouri, prohibit the use of public funds, such as Medicaid, to cover gender-affirming care for minors and in some instances, for all trans people regardless of age.
The state laws don’t explicitly prohibit coverage of mental health services, but they create legal uncertainty for providers, said Redfield, of the Williams Institute.
For example: A mental health visit that’s linked to a prohibited treatment might also not be covered by public insurance, she said.
Gender-affirming care, even when prescribed and overseen by medical professionals, can be expensive. And trans people are more likely to be uninsured and report cost-related barriers to care than cisgender adults, according to a KFF analysis from 2020.
Medicaid policies that exclude transgender-specific care were associated with less use of therapy and counseling, according to a 2020 analysis, while trans-inclusive Medicaid policies were associated with more use of therapy/counseling.
In Texas, Gooch said Equality Texas has partnered with Campaign for Southern Equality to offer small grants to families who ask for financial assistance in accessing gender-affirming care.
“Texas is a big state, and most of the places out of state [that offer gender-affirming care] are going to take you a five- to seven-hour drive or a flight,” said Gooch. “There’s a financial burden, a time cost, and making all of that simpler for the families is something important to us.”
The Campaign for Southern Equality, which advocates for LGBTQ+ rights across the South, recently launched the Southern Trans Youth Emergency Project, a regional effort to provide emergency grants and guidance to families of trans youth impacted by the gender-affirming care laws.
“As bans are passing and laws are changing, we’re working to do town halls and partnering with folks on the ground to make sure we’re getting out good, accurate information on what the law does and doesn’t say,” said Ivy Hill, director of gender justice for the group. The organization’s directory lists more than 500 trans-affirming health and legal service providers located across the South, about half of which see adolescents.
Pace also keeps a list of trans-affirming providers — from counselors to neurologists — available for people who call her clinic in Mississippi.
“These are people who deserve to have their basic health care needs met, just like anyone else,” Pace said.
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