As state-level restrictions and campaigns against gender-affirming care for minors have grown in scope and creativity over the past year, some transgender adults fear becoming the next target.
That day has not yet arrived, advocates say, although efforts are underway.
“We’re in a ‘never say never’ moment when it comes to trans health care,” said Vivian Topping, director of advocacy and civic engagement for the Federation for Equality, a coalition of state LGBTQ+ organizations. “But the attempts that were made didn’t get past the committee, even in a state like Mississippi, even in a state like Missouri.”
Mississippi introduced a failed bill earlier this year to ban gender-affirming care for anyone under 21. In Oklahoma, legislation with the same age limit was passed last year. Missouri tried and failed to pass a bill this year banning care for trans youth that included a vaguely written clause that could have affected adults: Lawmakers wrote that state health insurance plans renewed in 2023 would not be required to cover gender transition procedures without specifying an age. terms.
But even as restrictions on transgender youth have advanced, these proposals targeting adults have failed. Even if passed, however, bills banning care for trans youth have a weaker legal basis when applied to adults because they would infringe on adult autonomy, said attorney Taylor Brown. of the ACLU’s LGBTQ+ and HIV Project.
“I think it would be very difficult for states to step in like they do for minors and outright ban that kind of care with the same kind of penalties,” said Brown, who has argued many business on trans health care this year.
Apart from failed attempts at legislation, however, states are using other means to limit gender-affirming care. Approaches are slower and less public, and sometimes defined by a lack of protective action rather than direct restriction.
In 27 states, there are no laws providing LGBTQ+ inclusive insurance protections, according to the Movement Advancement Project (MAP), which tracks LGBTQ+ policy. (Conversely, 24 states and Washington, D.C., prohibit transgender exclusions in health insurance coverage.) Arkansas is the only state in the country to pass a law allowing private health insurers to refuse coverage for health-affirming care. gender without age limit. That law remains blocked, most recently by a federal court last month.
At least 15 states explicitly exclude gender-affirming care from their health benefits for state employees, according to the MAP tally in June. Eight states currently exclude gender-affirming care from Medicaid programs. In Florida, the latest state to join that list, the ban was quickly challenged and is awaiting a judge’s decision on whether to issue a preliminary injunction to block the law.
Olivia Hunt, director of policy at the National Center for Transgender Equality, believes the ultimate goal of bills focused on trans youth is to force trans people out of public life and restrict access to care affirming gender for all trans people, regardless of age.
“If you are trans or non-binary in the United States right now, whatever state you live in, your right to health care is under attack,” she said.
Restricting access to gender-affirming care for adults could take various forms, Hunt said, especially since many trans people already live in areas without it. The restrictions could look like a state redefining what gender-affirming care is covered in their “benchmark” or standard insurance plan; an insurance company charging more for hormones; doctors or nurses turning away trans patients, which is not allowed under the Affordable Care Act but remains a possibility in the current environment fueled by anti-trans bills, according to Hunt; or the only pharmacy or hospital in town claiming a religious exemption to a civil rights law that allows them to withhold prescriptions.
“There are many ways to undermine access to gender-affirming health care, or just access to health care in general for trans people,” she said.
The Florida Department of Health has asked the state’s Board of Medicine to institute a 24-hour waiting period for trans adults seeking hormone therapy or surgery — a waiting period reminiscent of some drug restrictions. abortion at the state level. At this point, Florida advocates see their home as a “proving ground” or flagship state for new anti-trans and anti-LGBTQ+ efforts.
Nikole Parker, director of transgender equality at Equality Florida, said she worries about how far supporters of anti-trans bills are willing to go to restrict care. Other members of the local community told him they feared their care could be cut altogether, or private insurance cuts following Medicaid curbs in the state despite no other bills reflecting the surge. .
While the growing fears are understandable, advocates say, the state-level bills that have been introduced are failing. And many emerging restrictions against transgender people are being met with a wave of lawsuits.
More likely, advocates said, states would use Medicaid exemptions and insurance exclusions for gender-affirming care as a way to restrict medical care for trans adults. Federal officials have signaled they are aware of the lack of political protections — the Biden administration and Democrats in Congress have promoted measures to make attacks on trans health care harder. The Department of Health and Human Services has pushed for explicit protections for gender-affirming care offered through health insurance plans provided through the Affordable Care Act, and two senators are pushing for relax restrictions on testosterone prescriptions.
Hormone therapy and gender-affirming surgery are crucial parts of transitioning for many trans adults. Alleviating gender dysphoria and aligning gender expression with identity through these treatments can reduce stress, reduce symptoms of depression and anxiety, and significantly reduce suicidal ideation. Similar benefits have been seen for trans youth who are on hormone therapy or taking puberty blockers.
In some parts of the country, access to this care is already going from difficult to impossible. For trans people in rural areas, those who can’t afford insurance battles, or those who face discriminatory doctor’s practices, a lack of resources and support is already preventing them from getting the care they need. need – no further bills or effort required.
Some trans people already live in rural areas where the nearest clinic is two to three hours away, Parker said. More restrictions would simply make it harder to access this care and put trans people who lack safe options at risk.
“Taking healthcare away from trans people won’t stop them from being trans,” she said. “What that will do is get people back to black market hormones, and that’s extremely dangerous.”
For Topping, one of the biggest consequences of anti-trans bills is the potential chilling effect on trans people trying to access care, the doctors they seek care from, and trans people who come out. And while gender-affirming care is accepted by major medical associations, current campaigns by far-right influencers against hospitals providing the care could compound this chilling effect, she said.
The growing rhetoric fueling attacks on these hospitals, coupled with pressure on teachers governed by laws restricting school discussions of gender and sexuality, is making a California-based teacher nervous about showing up to her students. peers as a transfeminine person.
The 36-year-old special education teacher, who asked to remain anonymous because she hasn’t dated most people in her life, knows she probably lives in one of the best states to begin her transition from gender. She does not feel threatened in terms of her ability to access care. But even within her “liberal bubble” in the Bay Area, she’s heard parents at her school recycle the same anti-trans rhetoric she’s heard elsewhere — that trans people are “healers.”
“I can see in my mind someone turning around, someone who knows me and worked for me for a while, just calling me a ‘groomer’ on the spot,” she said. “To have such hostile rhetoric surrounding something that has only changed my life in a positive way is pretty terrifying.”
Logan Casey, senior policy researcher and advisor for the Movement Advancement Project, pointed out that when states are unable to pass anti-trans bills, state actors find other avenues to achieve this goal. In Texas, this has taken the form of the state’s attorney general and governor calling for investigations into parents of trans children for alleged abuse. In Florida, pursuing Medicaid regulations and petitioning the board of medicine are other avenues taken that don’t require legislation, he said.
“It’s about trans people more broadly, and even in states where they’ve focused on young people, it’s basically been like a foot in the door to attack and restrict health care for all trans people of all ages “, did he declare.
Over the past year, many patients have told Quinn Jackson, a trans primary care physician who practices in Kansas City, Kansas, that they fear losing their access to gender-affirming care. He sees patients from Kansas and Missouri.
“There is a pervasive fear, and I believe legitimate, in the trans community that this attack on our rights and our ability to access care is not going to stop with minors. That over time they will likely seek to reduce access to care at older ages and eventually for everyone,” Jackson said.
When patients share this fear with him, Jackson tries to be reassuring. He says he and the clinic will stay unless they are forced to close – and that he can help facilitate referrals to other clinics if patients feel like moving is the best option.
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