Some States Are Quietly Trying to Limit Health Care Access for Trans Adults

As state-level restrictions and campaigns to stop gender-affirming treatment for minors have expanded in scope, creativity Some transgender adults have worried that they will be the next target in the last year.

Advocates say that the day is still not here, but they are making efforts.

“We’re in a ‘never say never’ moment when it comes to trans health care,” said Vivian Topping, director of advocacy and civic engagement of the Equality Federation, a coalition of state LGBTQ+ organizations. “But the attempts that have happened have not moved past committee, even in a state like Mississippi, even in a state like Missouri.”

Mississippi introducedA failed bill to ban gender-affirming care in the early part of this year was defeated. In OklahomaLast year, legislation with the same age limit was defeated. Missouri tried. failedThis year, a bill was passed banning trans youth care. It contained a vaguely-written clause that could have impacted adults. Legislators stated that state health insurance plans that were renewed in 2023 would not need to cover gender transition procedures.

These proposals, however, have not been approved despite the fact that transgender youths are now protected. Even if they passed, however, bills banning care for trans youth have weaker legal ground to stand on when applied to adults, because they would infringe on adults’ autonomy, said Taylor Brown, a staff attorney for the ACLU’s LGBTQ+ and HIV Project.

“I think it would be very difficult for states to come in like they’re doing for minors and prohibit that kind of care outright with the same kind of penalties,” said Brown, who has litigated numerous cases on trans health care this year.

Despite failed legislative attempts, states are finding other ways to limit gender affirming care. These methods are slower and less visible, and often refer to a lack of protection rather than a direct restriction.

According to the, there are no laws in 27 states that provide LGBTQ+ inclusive insurance protections. Movement Advancement Project(MAP), which tracks LGBTQ+ policies. (Conversely, 24 US states and Washington, D.C. prohibit transgender exclusions from health insurance coverage. Arkansas is the only state to have passed legislation allowing private health insurers to operate in Arkansas. refuseGender-affirming care is covered without age restrictions. This law is in force. blocked, most recentlyA federal court ruled in favor of the petition last month.

At least 15 states explicitly exclude gender-affirming care from their state employee health benefits, per MAP’s count as of June. Eight states currentlyMedicaid programs do not cover gender-affirming care. Florida is the state with the highest number of Medicaid recipients. recent stateTo join that list, the ban on entry was quickly challenged. awaits a judge’s decision on issuing a preliminary injunction to block the law.

Olivia Hunt, policy director of the National Center for Transgender Equality believes that bills focusing on trans youth have the ultimate goal to exclude trans people from public life and limit access to gender-affirming care for all trans people regardless of age.

“If you are trans or nonbinary in the United States right now, regardless of what state you live in, your right to health care is under attack,” she said.

Hunt stated that there are many ways to restrict access to gender-affirming care for adults, especially considering the fact that many trans people live in areas without it. 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 rejecting trans patients, which is not allowed under the Affordable Care Act, but is still a possibility in the current environment fueled by anti-trans bills, according to Hunt; or the only pharmacy or hospital in town invoking a religious exemption to a civil rights law that allows them to withhold prescriptions.

“There are a lot of ways that access to gender-affirming health care, or just access to health care generally for trans people, can be harmed,” she said.

Florida’s health department 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 reminiscenta few restrictions on abortion at the state level. Advocates at this point within Florida see their home as a “testing ground” or bellwether state for new anti-trans and anti-LGBTQ+ efforts.

Nikole Parker, director for transgender equality at Equality Florida said she is concerned about how far anti-trans bills supporters will go to limit care. Other members of the local community told her they fear for their care, or private insurance restrictions due to Medicaid restrictions within Florida.

Advocates say that while growing fears are understandable, state-level bills have failed to be passed. Many new restrictions against transgender persons are met with a flurry if lawsuits.

Advocates predicted that states would likely use Medicaid exemptions and insurance restrictions for gender-affirming services to limit the medical care of trans adults. Federal officials have signaled that they are aware of the lack of policy protections — both the Biden administration and Democrats in Congress have promoted measures to make attacks on trans health care more difficult. The Department of Health and Human Services (DHHS) has pushedThe Affordable Care Act provides explicit protections for gender affirming care through health insurance plans. two senators are pushingTo loosen restrictions on testosterone prescriptions

Many trans adults need hormone therapy and gender affirming surgery to make the transition easier. These treatments can help lower stress by reducing gender dysphoria, and aligning gender expression and identity. reduceSymptoms of depression and anxiety include: lessen suicidal ideation. Similar benefitsThey have been found trans youthPeople who have hormone therapy or are on puberty-blockers.

Accessing such care can be difficult in some parts of the country. For trans people rural areas, those who can’t afford insurance battles, or those faced with discriminatory doctor’s offices, a lack of resources and support already keeps them from getting the care they need — no further bills or effort required.

Parker stated that many trans people live in rural areas, where the nearest clinic is about a two- or three-hour drive away. Accessing care would be more difficult and could endanger transgender people who are unable to find safe options.

“Taking away health care from trans people won’t stop them from being trans,” she said. “What it will do is cause folks to go 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’re seeking that care from, and on trans people coming out. Even though gender-affirming healthcare is legal, acceptedCurrent medical associations are the largest. campaigns drivenFar-right influencers against hospitalsShe said that providing care could make the chilling effect worse.

One California teacher is nervous about coming out as transfeminine to her peers due to the growing rhetoric that is fueling attacks against these hospitals and the pressure on teachers governed under laws restricting school discussion on sexuality in schools.

The 36-year-old teacher in special education requested anonymity due to her inability to tell the rest of her family. She knows she is in the best place to start her gender transition. She doesn’t feel threatened about 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 “groomers.”

“I can see in my mind someone just turning around, someone who’s known me and worked for me for a while, just calling me a ‘groomer’ right there on the spot,” she said. “To have such hostile rhetoric around something that’s changed my life in nothing but positive ways, it’s pretty terrifying.”

Logan Casey, senior policy researcher and adviser for the Movement Advancement Project, pointed out that when states aren’t able to pass anti-trans bills, state actors find other paths to accomplish that goal. In Texas, that took the form of the state’s attorney general and governor calling for investigations into the parents of trans children for alleged abuse. He said that Florida’s Medicaid regulations can be followed and petitioning to the board of medicine can be pursued.

It’s about trans people more broadly, and even in states where they have focused on youth, that’s been basically like a foot in the door to attack and restrict health care for all trans people of all ages,” he said.

Quinn Jackson is a trans primary care doctor in Kansas City. Many patients have expressed concern about losing access to gender-affirming care over the past year. He sees patients both from Missouri and Kansas.

“There is a pervasive, and I believe legitimate, fear in the trans community that that attack on our rights and our ability to access care isn’t going to stop with minors. That, with time, they will probably seek to reduce access to care at higher ages and eventually for everyone,” Jackson said.

Jackson is reassuring when patients share their fears with him. He says that he and the clinic will remain unless they are forced to shutter — and that he can help facilitate referrals to other clinics if patients feel like moving is the best option.