In 2021, legislators introduced a record number of bills attacking transgender individuals, with many of the bills specifically designed to deny transgender youth access to gender-affirming medical care.
In April, Arkansas became the first state to ban gender-affirming services for transgender individuals under the age of 18. Transgender youth, their parents, and their health care providers filed suit, and the district court entered a preliminary injunction preventing the State from enforcing the law during the pendency of the case. The case is now at the 8th Circuit.
While that case is ongoing, late last month the Texas Attorney General issued an opinion claiming that gender-affirming care constitutes child abuse, prompting the Governor to send a letter to state agencies directing them to investigate “any reported instances” of these services. While the opinion and the letter have no legal effect, they create an atmosphere of fear and stigma that will undoubtedly prevent some transgender youth from receiving needed gender-affirming care. Two Texas families who had been subject to investigations by the State sued, and a court has granted a temporary restraining order that stops the State from investigating those families, but other investigations may proceed.
These actions fly in the face of the medical evidence. Gender-affirming services, which include counseling, medication to delay puberty, hormone therapy, and for some older transgender adolsecents, surgical care, are the standard of care. There is broad consensus within the medical community that gender-affirming services are safe and effective for transgender youth. In short, gender-affirming care for youth is good health care.
Unfortunately, even without bans in place, transgender youth already face a wide range of barriers to accessing gender-affirming care. Research shows that many transgender youth avoid seeking medical care of any kind for fear of experiencing discrimination or mistreatment. Black and Latine transgender people are even more likely to avoid seeking necessary medical care. to In addition, too few providers are trained to provide gender-affirming services to youth. In areas of the country where trained providers are available, transgender youth still report struggling to identify and access them.
The cost associated with gender-affirming care is another significant obstacle. While insurers should be covering gender-affirming care, they frequently do not. Several states explicitly prohibit Medicaid coverage of gender-affirming surgical care for youth and adults. Without coverage, youth often have no choice but to forgo the care that they need. In addition, lack of parent or caregiver approval can prevent many transgender youth from accessing care.
These and other barriers very clearly limit access to needed care. According to one study, only 46 percent of binary transgender youth access affirming medical intervenions. Nonbinary youth are significantly less likely to receive care, with only 8 percent accessing treatment.
Laws and policies that prevent transgender youth from accessing gender-affirming care will disproportionately harm low-income and at-risk youth. Estimates suggest that LGBTQ youth make up 30 percent of youth in the foster care system and 50 percent of youth experiencing homelessness, meaning that these youth are more likely to be low-income (and rely on Medicaid for their health coverage) than their heterosexual and cisgender peers. Moreover, both transgender foster youth and transgender homeless youth are disproportionately BIPOC. For these youth, accessing needed gender-affirming care is already quite difficult.
While youth who have supportive parents with means may ultimately be able to get the care they need by traveling to another state or even moving, low-income transgender youth in these states who lack financial support will have few options to get the care they need. The consequences can be dire, since going without needed care can exacerbate symptoms like depression and suicidality for transgender youth.
Thankfully, this week, HHS Secretary Xavier Becerra has affirmed that transgender youth are entitled to gender-affirming care and encouraged “[a]ny individual or family in Texas who is being targeted by a child welfare investigation because of this discriminatory gubernatorial order. . . to contact our Office for Civil Rights to report their experience.” HHS also released guidance to Child Welfare Agencies on serving LGBTQI youth, and also released guidance to providers on patient privacy, focusing on providers of transgender youth. Along with HHS, advocates must protect transgender youth and ensure they have access to the care they need by working to make sure that their states do not enact any additional barriers to accessing gender-affirming care for youth.
