Attacks on Gender-Affirming Care Extend to Transgender Adults

When Amir Ahuja, M.D., heard that the Human Rights Campaign declared a state of emergency for LGBTQ people, the first thing he thought was, “It’s about time.” Ahuja is the president of the Association of LGBTQ Psychiatrists.

The assault on the rights of LGBTQ people is not new, Ahuja pointed out. “When you’re growing up, though, and especially in the last 10 or 20 years, you have the false impression that things are going to get better on their own and the work is almost finished,” he said. “But the truth is, there are always those who will scapegoat LGBTQ people and try to use them politically to demonize the ‘other.’ ” Ahuja is the director of psychiatry at the Los Angeles LGBT Center.

Last year, a record-breaking number of anti-transgender bills were filed and passed in state legislatures across the country. This year, that record was broken again with “over 525 state bills introduced that attack the LGBTQ+ community,” according to the Human Rights Campaign, which made its state of emergency declaration in June. Over 220 of those bills target transgender people and more than 70 have become law as of June. That is more than double last year’s number.

Much of the misinformation and fearmongering around transgender people focuses on youth and echoes arguments made decades ago, Ahuja said. There are widespread claims, especially on social media platforms, that LGBTQ people are targeting children and that it is dangerous to allow them around youth.

“It’s a huge focus of people in a particular political spectrum, and I think it has led to what I would call ‘hysteria,’” Ahuja said. “It’s not only out of proportion to any type of real threat—it’s completely uninformed and inflammatory.”

States Begin Restricting Care for Adults as Well

A massive push in recent years has targeted gender-affirming care for transgender youth, banning access to that care, and criminalizing those who provide it. Yet recently, state legislatures have also set their sights on accesss to gender-affirming care for adults. Bills have been introduced in Kansas, Oklahoma, South Carolina, and Texas that would ban people as old as 21, or 26 in some cases, from accessing gender-affirming care.

In Missouri, the state’s attorney general issued an emergency regulation that severely restricted access to gender-affirming care for both adults and minors. The rule was terminated after Missouri’s legislature passed a bill banning such care for minors. Another law in Florida places new restrictions on care for transgender adults, such as creating informed consent requirements that must be completed in person rather than via telehealth. Missouri also banned transgender adults from accessing gender-affirming care through Medicaid. The state’s new law prohibits its Medicaid program from covering gender-affirming surgeries, hormone therapy, and puberty-blocking drugs. It also applies to people who are incarcerated.

The Missouri Psychiatric Physicians Association voiced its opposition to the legislation in Missouri. The recent attacks on the transgender community are highly concerning, said James Fleming, M.D., chair of the association’s Legislative Committee. “People with gender dysphoria are being caught up as victims in a culture war,” Fleming said. He noted the importance of the medical community standing up for these patients through open letters or other advocacy efforts.

Missouri is not the only state to recently ban gender-affirming care under Medicaid, but legal challenges are already successfully chipping away at those Medicaid exclusions. Last year, Florida’s Medicaid agency announced it would no longer cover several gender-affirming care services. In late June, a U.S. District Court Judge struck down the rule. “Gender identity is real,” Judge Robert Hinkle said in his ruling. He found that the plaintiffs “are Medicaid beneficiaries who are entitled to payment, as a matter of medical necessity, for puberty blockers or cross-sex hormones as appropriately determined by their multidisciplinary team of providers.”

Carl Charles, J.D., a senior attorney in the Southern Regional Office of Lambda Legal, one of the organizations representing the plaintiffs in the Florida case, said that his impression is that some see public insurance as “low-hanging fruit” in the effort to ban gender-affirming care altogether.

“Lawmakers in these states may think that voters, and indeed the general public, won’t care if they prohibit the care in Medicaid, but that couldn’t be further from the truth,” Charles said. According to a 2022 report by the Williams Institute at the UCLA School of Law, an estimated 276,000 individuals who identify as transgender are enrolled in Medicaid. Coverage of gender-affirming care is uncertain for 27% of them because they live in states where coverage rules are unclear, while 14% live in states where such services are expressly banned under Medicaid.

Charles explained that, until Florida’s rule in 2022 and now Missouri’s law, the number of states that explicitly banned Medicare coverage of gender-affirming care was dwindling. Over the past 10 to 20 years, LGBTQ advocates have been successfully taking down Medicaid exclusions one by one through the courts. Hopefully, he said, legal wins will continue to counter anti-LGBTQ legislation.

Fighting Misinformation With Medical Evidence

Legal challenges have played a hugely important role in protecting the rights of transgender youth and adults. That’s in part because they have relied on a wealth of well-supported clinical evidence, said Jennifer Levi, J.D., senior director of transgender and queer rights at GLBTQ Legal Advocates & Defenders (GLAD).

“The facts are well established about the underlying medical need, as well as the safety and efficacy of these treatments,” Levi said. “These state bans are entirely unsupported by evidence, and we’re seeing the judges recognize those established facts and reject witnesses that states have put forward who don’t have any expertise or knowledge in the field.”

Levi emphasized the importance of medical professionals educating their colleagues about the ongoing attacks on such a vulnerable patient population. “It’s so important for providers to understand that what states are doing in banning medical care is an attack on science and medicine,” Levi said. “Having allies speak out about protective policies and policies that are well grounded in science and medicine is hugely important.”

Ahuja echoed this point. He urged his fellow psychiatrists to voice their opposition to these bans and call them out as the political distractions they are. There is also a massive amount of misinformation around this issue, which psychiatrists are uniquely positioned to counter. “The best way to counter misinformation is for us to be trustworthy stewards of our information,” Ahuja said. “That both means that we should use the evidence we have without bias and that we should be honest about what we don’t know and where more research is needed.”

He also urged his colleagues to ask questions about aspects of gender-affirming care or the LGBTQ community that they don’t understand. “There’s no shame in asking questions,” he said. Psychiatrists should also ask their institutions for more training on providing care to LGBTQ patients. “If enough of us speak out, they will listen and provide more training and support.” ■