A growing number of states are banning gender-affirming health care and pursuing anti-LGBTQ+ legislation, contrary to ACP policy, which urges non-discrimination in health care. ACP opposes these restrictions on health care for transgender individuals, who already may face extreme barriers to accessing care, and strongly objects to any unnecessary government interference with any health care services.
In 2021, Arkansas became the first state in the country to ban gender-affirming health care for transgender minors. Since then, at least 12 other states have restricted gender-affirming services for minors and/or adults, and at least 30 states have introduced legislation in 2023 that would restrict access to this care. These bans are typically enforced by criminal, civil, and professional penalties for clinicians who provide services, as well as sometimes penalties for parents of children who support their children's access to essential health care. Although none of these laws have yet gone into effect amidst legal challenges brought by patients and physicians, ACP is extremely alarmed by this legislative trend, which is part of an overall proliferation of anti-LGBTQ+ legislation at the state level, with over 450 anti-LGBTQ+ bills introduced in 2023.
The Office of Population Affairs at the U.S. Department of Health and Human Services (HHS) defines gender affirming care as “an array of services that may include medical, surgical, mental health, and non-medical services for transgender and nonbinary people. For transgender and nonbinary children and adolescents, early gender-affirming care is crucial to overall health and well-being as it allows the child or adolescent to focus on social transitions and can increase their confidence while navigating the healthcare system.” Gender-affirming care is evidence-based medicine supported by many medical organizations, and study after study shows that gender-affirming care reduces depression and suicide among transgender youth. ACP and other leading medical organizations have condemned efforts to criminalize gender-affirming care and other evidence-based care as interference with the physician-patient relationship.
While restrictions initially focused on preventing minors from accessing gender-affirming care, states have increasingly targeted transgender health care for adults, with several states proposing bans through age 26 or restricting care for patients of all ages. Multiple states have also sought to limit both public and private insurance coverage of gender-affirming care, endangering access to essential care for transgender individuals of all ages. The Williams Institute at the UCLA School of Law found that over 146,300 transgender youth and young adults have lost or are at risk of losing access to care in states that have restricted access to gender-affirming care or are considering doing so, with 77,900 youth living in states that have taken action this year to ban or otherwise limit gender-affirming care either through legislation or executive action. In multiple states, bans would force transgender youth to medically detransition and stop successful gender-affirming treatments. With patients facing loss of medical care and their families and clinicians under legal threat, some transgender people and their families who can relocate have fled to states supportive of transgender rights, or are trying to navigate traveling out of state for care. Beyond immediate impacts, these laws drive stigma and endanger the wellbeing of LGBTQ+ youth. According to the Trevor Project’s 2021 National Survey on LGBTQ Youth Mental Health, 94 percent of LGBTQ+ youth reported that recent politics have negatively impacted their mental health.
ACP has decried discriminatory policies against LGBTQ+ people and objected in particular to the interference with the physician-patient relationship and penalization of evidence-based care. ACP believes that physicians and other health care professionals should not fear criminal punishment for providing the medical standard of care, nor should the government attempt to force disclosure of patient information related to gender-affirming care. ACP policy also calls for coverage of comprehensive transgender health care in private and public insurance plans. In addition to speaking out against these harmful laws, ACP has joined amicus briefs in legal challenges discriminating against transgender people and will continue to support legal and legislative efforts protecting against these medically unsound and dangerous restrictions.
While the majority of activity is taking place on the state level, federal policymakers have also taken action as part of this legislative trend. H.R. 1399 proposes a national ban on gender-affirming care for minors, and other legislation would implement other restrictions around education that have been introduced at the state level. Opponents of these restrictions have introduced measures including H.Res. 269/S.Res. 144, which would establish a transgender bill of rights under the Civil Rights Act to protect access to medical care and other essential services.
With the Biden Administration opposing these restrictions, the U.S. Department of Justice has issued guidance written to state attorneys general warning that bans on gender-affirming care are unconstitutional and violate multiple federal laws. In March 2022, HHS clarified that physicians and other health care personnel are not required to disclose patient information regarding gender-affirming care and that denials of care based on gender identity are illegal. HHS has also called for physicians and patients who believe they have been discriminated against on the basis of gender identity or disability in seeking to access gender-affirming care to file a complaint with the department’s Office of Civil Rights.
HHS finalized a new rule in April 2022 banning health coverage-related discrimination based on gender identity or sexual orientation, for which ACP expressed support. HHS additionally proposed a new rule in July 2022 that revises its interpretation of the Affordable Care Act’s anti-discrimination provision, Section 1557, which would strengthen legal protections for transgender patients and other groups impacted by sex-related discrimination. ACP wrote a letter to HHS Secretary Becerra providing comments in support of the proposed anti-discrimination rule.
Among the more than 450 anti-LGBTQ+ bills introduced in state legislatures in 2023, at least 119 of those bills have proposed restrictions in at least 30 states on gender-affirming care or transgender health care. While most restrictions have been legislative, some states have used administrative means to restrict access to gender-affirming care. In Florida, the state’s Agency for Health Care Administration prohibited Medicaid coverage for gender-affirming services for transgender patients of any age and the Board of Medicine and Board of Osteopathic Medicine passed new rules restricting gender-affirming care for minors at the encouragement of Governor Ron DeSantis. In Texas, Governor Greg Abbott instructed the Department of Family and Protective Services to investigate parents with transgender children for abuse, threatening custody removal and criminal penalties. The Missouri Attorney General proposed rules to go into effect in April 2023 that would severely restrict gender-affirming treatments for patients of all ages, featuring a requirement to provide medical disinformation and a number of medically unnecessary restrictions on clinicians who provide gender-affirming care that are similar to those ACP has opposed on reproductive health care services. The proposed Missouri rules also ban gender transition for any patient with autism or any mental health diagnosis, a type of restriction that has grown in prevalence within this legislative trend.
A number of states have taken actions to protect access to gender affirming care amidst this legislative trend. In 2023, more than a dozen states are considering laws to shield patients or clinicians from penalties associated with obtaining or providing gender-affirming care in states where it has been outlawed. Some of these bills also include protections for reproductive health services as abortion care has been criminalized following the overturn of Roe v. Wade or are being considered alongside similar bills amidst increasing criminalization of evidence-based care in the states. In total, 24 states and DC have prohibited insurance from excluding transgender health care services from coverage.
- Prohibiting Gender-Affirming Medical Care for Youth – Williams Institute at UCLA School of Law
- Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians (2015)
- ACP Statement of Principles on the Role of Governments in Regulating the Patient-Physician Relationship (2012)
- Annals of Internal Medicine Care of the Transgender Patient (2019)
- Medical News Today The “Life-Saving” Science Behind Gender Affirming Care for Youth
- HHS guidance on Gender-Affirming Care and Young People and statement in support of LGBTQ+ youth
- Amicus Brief filed by ACP and other medical organizations to Texas Supreme Court
- ACP Statements