gender reassignment discrimination in health and social care

Transgender Discrimination in Healthcare

The issue of LGBTQ rights has long been a source of heated debate both nationally and abroad. While the United States has undoubtedly moved towards greater inclusivity with the expansion of certain legal protections for the LGBTQ community and with increasing societal acceptance of and engagement in LGBTQ-inclusive discourse, the LGBTQ community continues to suffer from discrimination in the workplace, in education, and in healthcare.

Discrimination against LGBTQ individuals has become particularly visible in the healthcare setting in recent years. According to a review of anti-LGBTQ discrimination in US healthcare by the Human Rights Watch, patients reported a multitude of experiences with discrimination, including being denied fertility treatment, counseling, routine screening, and even pediatric care for their children. 1 A study published by the Center of American Progress in 2020 showed that 15% of 1,528 self-identified LGBTQ respondents endorsed postponing or avoiding medical treatment due to fear of discrimination. The transgender population, in particular, was shown to suffer from even more pervasive discrimination. Of the transgender respondents, 3 in 10 endorsed postponing or avoiding medical treatment due to discrimination, and 1 in 3 reported the need to teach providers about their sexual identity in order to receive adequate care. 2

The problem of discrimination against the transgender patient population and the LGBTQ community at large begins at the federal level. In January 2021, the US Department of Health and Human Services under the Trump Administration published a final rule rescinding Obama-era protections barring providers receiving federal funding from discrimination on the basis of gender identity or sexual orientation. 3 This policy change is particularly damaging to the LGBTQ community, as it allows providers to deny patients access to important services, including sexual health screenings, opioid treatment, detoxification programs, and health professional training.

While this policy change was addressed by the Biden administration’s recent executive order reaffirming anti-discrimination protections based on the Supreme Court case Bostock v. Clayton County , it ultimately falls short in the security it offers to the LGBTQ community. 4 Executive orders, however, are limited in their durability and longevity. In contrast to federal statutory law, which is passed by the US Congress and signed by the president, executive orders are limited in their jurisdiction and can only dictate federal government operations within the boundaries outlined by the Congress. In addition, executive orders are not permanent and subject to alterations with changes in administrations. These limitations ultimately reduce the ability of the Biden administration’s executive order to offer a lasting solution to the problem of discrimination for this population.

The lack of federal protections for transgender patients is further exacerbated by discrimination at the individual provider level. However, physician discrimination against the transgender patient population seems to stem more often from a deficit of knowledge than from a deficit of tolerance. 5 Even the most well-intentioned providers may fall short in their ability to provide adequate care to transgender patients without sufficient training in healthcare issues unique to these patients, such as hormone therapy, sex-reassignment surgery, and transition care. 6 In a recent study published in the Annals of Family Medicine , only about 69% of surveyed physicians felt adequately prepared to provide care to transgender individuals, although 86% of surveyed physicians were willing to provide care to these individuals. 7

Underlying the discrimination faced by transgender patients in the healthcare setting is a fundamental lack of provider competency in transgender care. The failure to understand the transgender patient experience may not only contribute to healthcare practice perceived as discriminatory by patients, but may even perpetuate discrimination, as providers lacking adequate training in transgender healthcare issues may be more likely to perceive being transgender as deviant. Increasing provider education on the psychosocial aspects of being transgender as well as on healthcare screening, diagnoses, and treatments unique to this population may reduce the barriers faced by transgender patients in receiving quality care. 8

Ultimately, increased training in transgender healthcare must also be accompanied by the enactment of lasting legal protections against discrimination in the healthcare setting for transgender and other LGBTQ patients. While this process has been initiated by the recent passage of the Equality Act by the House of Representatives, the bill’s ability to withstand pushback from the Senate remains to be seen. 9 Regardless of this outcome, legislation that expands LGBTQ access to quality healthcare, secures insurance coverage for transition-related treatments, and emphasizes anti-discrimination policy is crucial for ensuring more equitable healthcare for the LGBTQ community. 

Author Bio:

Alexandria Lee

Alexandria Lee is a third year medical student at Loma Linda University School of Medicine. She graduated from UCLA with a degree in Ecology and Evolutionary Biology and has always been interested in intersectionality in medicine. When she’s not studying, she can be found at a coffee shop in LA.

• https://www.hrw.org/sites/default/files/report_pdf/us_lgbt0718_web.pdf
• https://www.americanprogress.org/issues/lgbtq-rights/reports/2020/10/06/491052/state-lgbtq-community-2020/
• https://public-inspection.federalregister.gov/2021-00207.pdf
• https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-preventing-and-combating-discrimination-on-basis-of-gender-identity-or-sexual-orientation/
• https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/12/health-care-for-transgender-individuals
• https://www.aafp.org/news/practice-professional-issues/20181214transgendercare.html
• https://www.annfammed.org/content/16/6/555.full
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5344057/
• https://thehill.com/homenews/house/540558-house-passes-sweeping-protections-for-lgbtq-people?userid=645683

Gender reassignment discrimination and the NHS

• Using your device

NHS bodies, in their roles as both employer and service provider, increasingly find themselves subject to complaints of discrimination on the grounds of gender reassignment, due to a growing awareness and understanding within the trans community of their rights as employees and patients.

It is therefore important that NHS bodies ensure that they have adequate training and policies in place for the prevention of discrimination against transgender employees or service users.

The two key pieces of legislation that protect transsexual people are the Equality Act 2010 (EqA 2010) and the Gender Recognition Act 2004 (GRA 2004).

The Equality Act 2010

Discrimination under the eqa 2010.

The EqA 2010 provides legal protection from discrimination and harassment. Gender reassignment is one of the nine protected characteristics covered by the Act. A person has the protected characteristic of gender reassignment if that person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning their sex by changing physiological or other attributes of sex.

Under the Act, a reference to a person who has the protected characteristic of gender reassignment is a reference to a transsexual person. Therefore, a woman making the transition to being a man and a man making the transition to being a woman both share the characteristic of gender reassignment.

A key point to note about the definition of gender reassignment under the EqA 2010, is that a person who ‘is proposing to undergo’ the process of changing their sex is protected i.e. they need not have undertaken any actual steps towards the process of transitioning. Further, a person living in the opposite gender without having undergone any medical procedures will be protected. Unlike earlier legislation, there is no requirement to be under medical supervision to qualify for protection under the EqA 2010.

There are five types of prohibited discrimination in respect of gender reassignment:

• Direct discrimination – when a transsexual person is treated less favourably than others because of gender reassignment
• Indirect discrimination – where a transsexual person is particularly disadvantaged by a provision, criterion or practice which applies to everyone
• Harassment – when unwanted conduct related to gender reassignment causes an intimidating, hostile, humiliating or offensive environment for that person
• Victimisation – when a person is subjected to a detriment because they have made or supported a complaint about gender reassignment discrimination
• Absences from work – where an employee is treated less favourably in relation to absences from work because of gender reassignment. This is the only type of prohibited discrimination specific to transsexual people

Case example

One issue that employers are likely to face in relation to transsexual employees is use of single-sex facilities. For example, it is likely, and understandably so, that person will want to use the toilet facilities of the gender to which they are transitioning. In the leading authority on this issue Croft -v- Royal Mail Group plc [2003], the Court of Appeal upheld a decision of an employment tribunal that it was not discrimination to require a pre-operative male to female transsexual employee to use the disabled toilet as opposed to the female toilet facilities during the transition process.

However, the approach in this case should not be regarded as best practice. The recruitment and retention of transgender staff guidance issued by the Government Equalities Office (GEO) Guide states that a trans person should be free to select the facilities appropriate to the gender in which they present and that when a trans person starts to live in their acquired gender role on a full-time basis they should have the right to use the facilities for that gender. Further, the Department of Health Guidance for NHS Trusts sets out that it is not good practice to require a transsexual person to use the disabled facilities and it is not acceptable to require a transsexual person to use the facilities of their assigned gender.

Exceptions: when gender reassignment discrimination may be lawful

Gender reassignment discrimination may be permitted in certain limited circumstances. The EqA 2010 provides for an ‘occupational requirement’ exception that employers can rely on in discrimination claims. This enables employers, in limited circumstances, to require that, having regard to the nature or context of the work, only people who are not transsexuals can do the job. The explanatory notes in the EqA 2010 give the following example of an occupational requirement; ‘a counsellor working with victims of rape might have to be a woman and not a transsexual person, even if she has a gender recognition certificate, in order to avoid causing victims further distress.’ This may also apply to NHS staff employed to help victims of rape or other sexual assault.

Application to the NHS

In addition to NHS employees, patients must not be subjected to discrimination by NHS Trusts. The EqA 2010 prohibits discrimination by a service provider (concerned with the provision of a service to the public) against a person requiring the service. Therefore, NHS trusts must not discriminate against transsexual patients because they have the protected characteristic of gender reassignment.

However, there is an exception in the Act for single-sex only services (for example, a group counselling session provided only for female victims of sexual assault) but NHS trusts must be certain that the provision of separate services is a proportionate means of achieving a legitimate aim.

NHS bodies must also have regard to the Public Sector Equality Duty set out in Section 149 EqA 2010, which sets out that they must have due regard to eliminating discrimination prohibited by the EqA 2010 and advancing equality of opportunity and fostering good relations between those who share a protected characteristic and people who do not share it.

Gender Recognition Act 2004

The Gender Recognition Act 2004 (the Act) allows transsexual people to gain legal recognition of their acquired gender by registering for a Gender Recognition Certificate (GRC). The application is made to the Gender Recognition Panel who will determine whether a GRC should be issued on the basis that the applicant has lived in their acquired gender for two years and intends to live the acquired gender until death. An applicant does not have to have had gender reassignment surgery, but have been diagnosed as gender dysphoric. Where a full GRC has been issued to a person, their gender becomes for all purposes the acquired gender.

Prohibition on disclosure of information

The Act has important implications for NHS trusts, particularly in relation to the provisions on prohibition of disclosure of information relating to a person’s application for a GRC or, if a GRC is issued, their previous gender. Under section 22 of the Act, it is a criminal offence for a person who has acquired, in an official capacity, protected information regarding an individual’s gender identity to disclose that information to any other person. This clearly affects NHS bodies as employers and in the supply of services to the public, as they are likely to acquire such information in relation to their employees or patients.

An example provided by the workplace and gender reassignment: Guide for staff and managers (a:gender Guide) is of someone working in HR with access to an employee’s personal file, disclosing the fact that the employee was born a different gender, without the employee’s prior consent.

Potential defences

There are a number of defences to this prohibition set out in section 22(4) of the Act. These include where the information does not enable that person to be identified and where the person has agreed to the disclosure of the information.

In addition, there is a further defence which will have particular importance to NHS bodies as service providers. The Gender Recognition (Disclosure of Information) (England, Wales and Northern Ireland) (No2) Order 2005 provides a defence in relation to disclosure for medical purposes. It will not be an offence under section 22 of the Act to disclosure protected information if the disclosure is made to a health professional, for medical purposes, and the person making the disclosure reasonably believes that the subject has given consent to the disclosure or cannot give such consent.

Practical considerations for NHS bodies

The a:gender Guide states that ‘it is the antithesis of the intentions of the privacy provision included in the GRA 2004 to ask or expect an individual to evidence they have gender recognition. Given the wider privacy protection applicable to all, it is best practice to assume any transsexual person has gender recognition and treat them accordingly’.

Care should be taken to use appropriate names and terminology in HR and patient records in relation to transsexual people. Where a person is transgender, it is important not to refer to this fact in patient or HR records unless the person has consented to it. In respect of employees, this may involve issuing them with a new set of HR records.

In relation to transgender patients, NHS/Department of Health guidance is that they should be issued with a new set of medical records to reflect their new gender status. NHS trusts may find themselves in a difficult position when there are medical reasons why a transgender patient’s previous gender needs to be referred to. In these circumstances, the medical professionals should seek consent from the patient for their gender history being recorded in their notes and steps should be taken to ensure that access to those notes is limited to those who need to be aware of the patient’s gender history for clinical reasons.

Department of Health guidance recommends that all staff are trained on these issues in relation to transgender patients and employees. Our specialist employment team can provide training on the legislation in this area and its implications for NHS bodies.

• Healthcare law

Health and social care

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The adult trans care pathway

The adult trans care pathway focuses on the care of people with:

• variations of sex characteristics (VSC)
• trans people aged 17 years and older and transitioning their gender
• non-binary people aged 17 years and older and transitioning their gender

The trans care pathway refers mainly to patients transitioning gender medically, rather than socially or legally.

People with VSC, trans and non-binary people may be particularly vulnerable to receiving poor care. This may be for reasons such as a lack of training for staff, inefficient monitoring of trans status, and potential transphobia.

The General Medical Council (GMC) has produced guidance on trans care . It states that trans and non-binary people experience the same health problems as everyone else and that healthcare professionals must assess, provide treatment for and refer trans patients in the same way as other patients.

Terminology

• Transgender is usually shortened to ‘trans’. It describes people whose felt sense of gender (gender identity) is not the same as the gender assigned at birth on the basis of genital appearance
• Non-binary is an umbrella term to describe gender identities that are not only masculine or only feminine. They are outside the ‘gender binary’ of male and female. Not all non-binary people identify as trans.
• Gender affirmation is the process a transgender person goes through to change their physical sexual characteristics to match their gender identity. This typically involves a combination of surgical procedures and hormone treatment.
• Gender reassignment (wording of the Act to mean trans status) is one of the nine protected characteristics under the Equality Act 2010. The Act recognises prejudice and discrimination that trans and non-binary people may face in receiving both services and employment.
• Gender variance is an umbrella term to describe gender identity, expression, or behaviour that falls outside culturally defined norms associated with a specific assigned gender.
• Cisgender relates to a person whose sense of gender identity corresponds with their sex assigned at birth.

When we assess health and care services, we consider equality and whether services are providing high-quality care for all people, including people on the trans care pathway. We judge whether services are meeting the equality aspects of the Health and Social Care Act regulations, particularly:

• Regulation 9 (Person centred care)
• Regulation 10 (Dignity and Respect)

When we assess services, we will look at how they provide care for people who are on the trans care pathway, where this is relevant. This will take into account the local access arrangements to gender services.

Adult trans care pathway: what CQC expects from GP practices

Adult trans care pathway: what CQC expects from maternity and gynaecology services

Adult trans care pathway: what CQC expects from speech and language services

Further information

• How to find a gender identity clinic (NHS England)
• Inclusive language (NHS Digital Service Manual)
• Transgender issues in later life (Age UK)
• Trans healthcare (General Medical Council)
• Support for GPs and trans patients (LGBT Foundation/NHS in Greater Manchester)
• Gender Dysphoria Clinical Programme (NHS England)
• The role of the GP in caring for gender-questioning and transgender patients (Royal College of General Practitioners)
• Fair care for trans and non-binary people (Royal College of Nursing)
• The Royal College of Psychiatrists position statement Supporting transgender and gender diverse people
• LGBT in Britain: Trans report (Stonewall and YouGov)
• Standards of care for the Health of Transsexual, Transgender, and Gender Nonconforming People: Version 7 (World Professional Association for Transgender Health)

Find out more

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The White House 1600 Pennsylvania Ave NW Washington, DC 20500

FACT SHEET: Biden- ⁠ Harris Administration Advances Equality and Visibility for Transgender Americans

Today, the Biden-Harris Administration recognizes Transgender Day of Visibility, an annual celebration of the resilience, achievements, and joy of transgender people in the United States and around the world. Every American deserves the freedom to be themselves. But far too many transgender Americans still face systemic barriers, discrimination, and acts of violence. Today, the Administration once again condemns the proliferation of dangerous anti-transgender legislative attacks that have been introduced and passed in state legislatures around the country. The evidence is clear that these types of bills stigmatize and worsen the well-being and mental health of transgender kids, and they put loving and supportive families across the country at risk of discrimination and harassment. As the President has said, these bills are government overreach at its worst, they are un-American, and they must stop. Transgender people are some of the bravest people in our nation. But nobody should have to be brave just to be themselves. Today, the Biden Administration announced new actions to support the mental health of transgender children, remove barriers that transgender people face accessing critical government services, and improve the visibility of transgender people in our nation’s data.

Reinforcing federal protections for transgender kids. The Justice Department announced today that it has issued a letter to all state attorneys general reminding them of federal constitutional and statutory provisions that protect transgender youth against discrimination, including when those youth seek gender-affirming care. Advancing dignity, respect, and self-determination for transgender people by improving the traveler experience. For far too long, transgender, non-binary, and gender non-conforming Americans have faced significant barriers to travelling safely and many have not had their gender identity respected as they travel within the United States and around the world. To create a safer and more dignified travel experience, the Biden Administration is announcing the following changes.

• The Department of State is announcing that beginning on April 11, 2022, all U.S. citizens will be able select an “X” as their gender marker on their U.S. passport application. This is a major step in delivering on the President’s commitment to expand access to accurate identification documents for transgender and non-binary Americans. Information on how to apply will be available at travel.state.gov/gender .
• Implementing enhanced screening technology. The Transportation Security Administration (TSA) will soon begin updating its Advanced Imaging Technology (AIT) body scanners with new technology that will increase security and efficiency by reducing false alarm rates and pat-downs for the traveling public. By replacing the current, gender-based system with this more accurate technology, TSA will improve the customer experience of transgender travelers who have previously been required to undergo additional screening due to alarms in sensitive areas.  This new technology will help to improve the experience of travelers, particularly those who are transgender and non-binary travelers. TSA will begin deploying this new technology in airports throughout the country later this year.
• Expanding airline partnerships to enhance the overall travel experience.  TSA is working closely with air carriers across the nation to promote the use and acceptance of the “X” gender marker to ensure more efficient and accurate passenger processing. As of March 31st, two major domestic air carriers already offer a third gender marker option in their travel-reservation systems, with a third air carrier planning to offer this option in the Fall of 2022.
• Streamlining identity validation. TSA has updated its Standard Operating Procedures to remove gender considerations when validating a traveler’s identification at airport security checkpoints. This ensures that TSOs can accurately and efficiently validate each traveler’s identity while avoiding unnecessary delays.
• Updating TSA PreCheck and CBP Trusted Traveler Programs enrollment to include “X” gender markers. The Department of Homeland Security is beginning the process of adding “X” gender markers options in Trusted Traveler programs and the TSA PreCheck program to enhance access for transgender, non-binary, and gender non-conforming travelers to these programs.

Providing resources for transgender kids and their families. Transgender children are put at higher risk of attempted suicide or mental health challenges when they face bullying, rejection, or denial of health care. The Biden Administration is releasing several new resources to help transgender children and their parents thrive:

• Providing mental health resources for transgender youth.  In recent months, multiple states have removed critical information about mental health resources for LGBTQI+ youth from official state websites. Transgender youth often face significant barriers in accessing supportive resources, and are at greater risk of attempted suicide. In response, the Department of Health and Human Services released a new website that offers resources for transgender and LGBTQI+ youth, their parents, and providers. These resources include best practices for affirming an LGBTQI+ child, and information about suicide prevention services.
• Expanding trainings to support transgender and nonbinary students in schools. The Office of Safe and Supportive Schools in the Department of Education will offer new training for schools with experts and school leaders who will discuss the challenges faced by many transgender and nonbinary students and strategies and actions for providing support.
• Confirming the positive impact of gender affirming care on youth mental health. The Substance Abuse and Mental Health Services Administration (SAMHSA) has posted LGBTQI+ Youth – Like All Americans, They Deserve Evidence-Based Care , in which Miriam Delphin-Rittmon, Ph.D., HHS Assistant Secretary for Mental Health and Substance Use and the leader of SAMHSA, shares how to engage LGBTQI+ youth, the evidence behind the positive effects of gender affirming care, and available resources for LGBTQI+ youth, their families, providers, community organizations, and government agencies.
• Confirming that gender-affirming care is trauma-informed care. The National Child Traumatic Stress Network (NCTSN), which is administered by the Substance Abuse and Mental Health Services Administration, is releasing new information for providers confirming that providing gender-affirming care is neither child maltreatment nor malpractice.
• Providing resources on the importance of gender affirming care for children and adolescents. The Office of the Assistant Secretary for Health has developed a resource to inform parents and guardians, educators, and other persons supporting children and adolescents with information on what is gender-affirming care and why it is important to transgender, nonbinary, and other gender expansive young people’s well-being.

Improving access to federal services and benefits for transgender Americans.  With support and coordination from the U.S. Digital Service, federal agencies are removing barriers to access government services by improving the customer experience of transgender, non-binary, and gender non-conforming Americans:

• Accessing retirement savings. The Social Security Administration is announcing that it is removing the requirement that transgender people show proof of identity such as doctor’s notes in order to update their gender information in their social security record by the fall of 2022. This will significantly improve transgender individuals’ experience in accessing their retirement benefits, obtaining health care, and applying for jobs.
• Filing an employment discrimination complaint . The U.S. Equal Employment Opportunity Commission (EEOC) is announcing that it will promote greater equity and inclusion for members of the transgender community by giving individuals the option to select an “X” gender marker during the voluntary self-identification questions that are part of the intake process for filing a charge of discrimination.
• Applying for federal student aid. The Department of Education plans to propose next month that the 2023-24 FAFSA (Free Application for Federal Student Aid) will include an opportunity for applicants to indicate their gender identity as well as their race/ethnicity when applying for federal financial aid. The questions, which will be posted for public comment, will be in a survey that accompanies the application. This privacy-protected information would help to inform the Department about possible barriers students, including transgender and nonbinary students, face in the financial aid process.
• Visiting the White House.  The White House Office of Management and Administration is announcing that it is beginning the process of implementing updates that will improve the White House campus entry process for transgender, gender non-conforming, and non-binary visitors by adding an “X” gender marker option to the White House Worker and Visitor Entry System (WAVES) system. This change will ensure that transgender, non-binary, and gender nonconforming people can visit the People’s House in a manner that respects and affirms their gender identity.

Advancing inclusion and visibility in federal data. In too many critical federal surveys and data systems, transgender, non-binary, and gender non-conforming people are not fully reflected. To improve visibility for transgender Americans, agencies are announcing new actions to expand the collection and use of sexual orientation and gender identity (SOGI) data.

• The White House announced that the President’s proposed Fiscal Year 23 budget includes $10 million in funding for additional critical research on how to best add questions about sexual orientation and gender identity to the Census Bureau’s American Community Survey, one of our nation’s largest and most important surveys of American households. This data collection will help the federal government better serve the LGBTQI+ community by providing valuable information on their jobs, educational attainment, home ownership, and more.
• The Department of Health and Human Services has released the findings of the federal government’s first-ever user research testing conducted with transgender Americans on how they want to see themselves reflected on Federal IDs. This groundbreaking user research by the Collaborating Center for Question Design and Evaluation Research (CCQDER) at the National Center for Health Statistics (NCHS) directly informed the State Department’s adopted definition of the “X” gender marker.
• The Department of Health and Human Services  has released a comprehensive new consensus study on Measuring Sex, Gender Identity, and Sexual Orientation. This work, commissioned by the National Institutes of Health and carried out by the National Academies of Sciences, Engineering, and Medicine, will inform additional data collections and future research in how to best serve LGBTQI+ Americans.

These announcements build on the Biden-Harris Administration’s historic work to advance equality for transgender Americans since taking office, including: Combatting legislative attacks on transgender kids at the state level.

• Condemning anti-transgender bills. The President has consistently made clear that legislative attacks against transgender youth are un-American, and are bullying disguised as legislation. In his March, 2022 State of the Union Address, the President said, “The onslaught of state laws targeting transgender Americans and their families is wrong. As I said last year, especially to our younger transgender Americans, I will always have your back as your President, so you can be yourself and reach your God-given potential.” The White House has also hosted listening sessions with transgender youth and advocates in states across the country that are impacted by anti-transgender legislative attacks.
• Reaffirming that transgender children have the right to access gender-affirming health care. In March, following state actions that aim to target parents and doctors who provide gender-affirming care to transgender children with child abuse investigations, the Department of Health and Human Services took multiple actions to support transgender children in receiving the care they need and promised to use every tool available to protect LGTBQI+ children and support their families.
• Department of Justice statements of interest and amicus briefs. The Department of Justice’s Civil Rights Division has filed Statements of Interest and amicus briefs in several matters to protect the constitutional rights of transgender individuals, including in Brandt v. Rutledge , a lawsuit challenging legislation restricting access to gender-affirming care for transgender youth; B.P.J. v. West Virginia State Board of Education , a lawsuit challenging legislation restricting participation of transgender students in school sports; Corbitt v. Taylor , a lawsuit challenging legislation restricting the ability to change gender markers on state driver’s licenses; and Adams v. School Board of St. John’s County , which involves the right of a transgender boy to use the boys’ restroom at his school.

Advancing civil rights protections for transgender Americans

• Fighting for passage of the Equality Act.  President Biden  continues to call  on the Senate to pass the Equality Act, legislation which will provide long overdue federal civil rights protections to transgender and LGBTQI+ Americans and their families. As the White House has  said , passing the Equality Act is key to addressing the epidemic levels of violence and discrimination that transgender people face. The Administration’s first Statement of Administration Policy was in support of the Equality Act, and the White House has convened national leaders to discuss the importance of the legislation.
• Signing one of the most comprehensive Executive Orders on LGBTQI+ rights in history.  Within hours of taking office, President Biden signed an  Executive Order  which established that it is the official policy of the Biden-Harris Administration to prevent and combat discrimination against LGBTQI+ individuals, and to fully enforce civil rights laws to prevent discrimination on the basis of gender identity or sexual orientation. This Executive Order is one of the most consequential policies for LGBTQI+ Americans ever signed by a U.S. President. As a result of that Order, the Departments of Health and Human Services , Housing and Urban Development , Education , Consumer Financial Protection Bureau , and Justice have announced that they are expanding non-discrimination protections for transgender people in health care, housing, education, credit and lending services, and community safety programs.

Supporting transgender service members and veterans

• Reversing the discriminatory ban on transgender servicemembers.  In his first week in office, President Biden  signed  an Executive Order reversing the ban on openly transgender servicemembers serving in the Armed Forces, enabling all qualified Americans to serve their country in uniform. President Biden believes that an inclusive military strengthens our national security As a result of his Executive Order, the Department of Defense issued new  policies  which prohibit discrimination against transgender servicemembers, provide a path for transgender servicemembers to access gender-affirming medical care, and require that all transgender servicemembers are treated with dignity and respect.
• Supporting transgender veterans. To ensure that transgender veterans are treated with dignity and respect, the Department of Veterans Affairs (VA) launched an  agency-wide review  of its policies and practices to ensure that transgender veterans and employees do not face discrimination on the basis of gender identity or expression. In June, VA also announced that it is beginning the regulatory process to remove restrictions that prevent transgender veterans from accessing the gender-affirming care they need and deserve.

Responding to the crisis of anti-transgender violence and advancing safety

• Establishing a White House-led interagency working group on anti-transgender violence. To address the crisis of anti-transgender stigma and violence, during Pride Month in 2021 the White House established the first Interagency Working Group on Safety, Opportunity, and Inclusion for Transgender and Gender Diverse Individuals. The Working Group is co-led by the White House Domestic Policy Council and Gender Policy Council. To inform the priorities of the Working Group, throughout the fall of 2021 the White House convened 15 historic listening sessions with transgender and gender diverse people, advocates, and civil rights leaders from across the country and around the world, including a White House roundtable with transgender women of color .
• Releasing a White House report uplifting the voices of transgender people on gender-based violence and discrimination. On Transgender Day of Remembrance, the White House released a  report  sharing the perspectives from White House listening sessions, uplifting the voices and advocacy of transgender people throughout the country, and highlighting over 45 key, early actions the Biden-Harris Administration is taking to address the root causes of anti-transgender violence, discrimination, and denial of economic opportunity.
• Department of Justice civil rights enforcement actions. On September 14, 2021, the Department of Justice announced that it was launching a statewide civil investigation into Georgia’s prisons, which includes a focus on sexual abuse of transgender prisoners by other prisoners and staff. The Department of Justice’s Civil Rights Division and U.S. Attorney’s Office for the District of Puerto Rico also obtained a federal indictment charging three men with hate crimes for assaulting a transgender woman because of her gender identity.
• Ensuring non-discrimination protections in community safety programs. The Department of Justice issued a Memorandum from the Assistant Attorney General for Civil Rights regarding the application of Bostock v. Clayton County to the nondiscrimination provisions of the Safe Streets Act, the Juvenile Justice and Delinquency Prevention Act, the Victims of Crime Act, and the Violence Against Women Act to strengthen non-discrimination protections for transgender and LGBTQI+ individuals in key community safety programs.
• Strengthening protections for transgender individuals who are incarcerated. In January 2022 the Bureau of Prisons revised its manual on serving transgender offenders , improving access to gender-affirming care and access to facility placements that align with an inmate’s gender identity.
• Honoring those lost to violence.  The White House and the Second Gentleman of the United States hosted a first of its kind vigil in the Diplomatic Room of the White House to honor the lives of transgender and gender diverse people killed in 2021, and the countless transgender and gender diverse people who face brutal violence, harassment, and discrimination in the United States and around the world. The President also released a statement honoring the transgender people who lost their lives to violence.
• Advancing safety and justice for transgender and Two-Spirit Indigenous people. LGBTQI+ Native Americans and people who identify as transgender or “Two-Spirit” are often the targets of violent crimes. On November 15, 2021, President Biden signed an Executive Order on Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People. The Executive Order directs federal agencies to work hand in hand with Tribal Nations and Tribal partners to build safe and healthy Tribal communities to address the crisis of Missing and Murdered Indigenous People, including LGBTQI+ and “Two-Spirit” Native Americans.

Advancing health equity and expanding access to gender-affirming health care to support transgender patients

• Protecting transgender patients from health care discrimination. The Department of Health and Human Services (HHS) announced that it would interpret and enforce section 1557 of the Affordable Care Act’s prohibition on discrimination on the basis of sex in certain health programs to prohibit discrimination on the basis of gender identity and sexual orientation.
• Advancing gender-affirming care as an essential health benefit.  In 2021, the Centers for Medicare and Medicaid Services (CMS) approved the first ever application from a state to add additional gender-affirming care benefits to a state’s essential health benefit benchmark plan.
• Advancing health equity research on gender-affirming care.  The National Institutes of Health (NIH) announced that it will increase funding for research on gender-affirming procedures to further develop the evidence base for improved standards of care. Research priorities include a more thorough investigation and characterization of the short- and long-term outcomes on physical and mental health associated with gender-affirming care.
• Ending the HIV crisis among transgender and gender diverse communities.  In December, 2021, in recognition of World AIDS Day, the White House Office of National AIDS Policy released a revised National HIV/AIDS Strategy which now identifies transgender and gender diverse communities as a priority population in the federal government’s strategy to end the HIV epidemic.
• Advancing access to gender-affirming care through Ryan White HIV/AIDS Program. The Health Resources and Services Administration announced that it has released a letter encouraging Ryan White HIV/AIDS Program service providers to provide access to gender affirming care and treatment services to transgender and gender diverse individuals with HIV. The letter reaffirms the importance of providing culturally-affirming health care and social services as a key component to improving the lives of transgender people with HIV.
• Ensuring transgender patients can access birth control. In 2021 HHS issued a final rule to strengthen the Title X family planning program, fulfilling the Biden-Harris Administration’s commitment to restore access to equitable, affordable, client-centered, quality family planning services. The rule requires family planning projects to provide inclusive care to LGBTQI+ persons. Additionally, the rule prohibits discrimination against any client based on sex, sexual orientation, gender identity, sex characteristics, or marital status.

Supporting transgender students and their families

• Ensuring educational environments are free from sex discrimination and protecting LGBTQI+ students from sexual harassment.  President Biden signed an  Executive Order  recommitting the Federal Government to guarantee educational environments free from sex discrimination, including discrimination on the basis of sexual orientation or gender identity. The Executive Order charged the Department of Education with reviewing the significant rates at which students who identify as LGBTQ+ are subject to sexual harassment, including sexual violence. The Department of Education has announced that it intends to propose amendments to its Title IX regulations this year.
• Protecting the rights of transgender and gender diverse students. The Department of Education has affirmed that federal civil rights laws protect all students, including transgender and other LGBTQI+ students, from discrimination. The Department published a notice in the Federal Register announcing that it interprets Title IX’s statutory prohibition on sex discrimination as encompassing discrimination based on sexual orientation and gender identity.
• Department of Justice memorandum on Title IX. The Department of Justice issued a memorandum regarding the application of Bostock to Title IX.
• Speaking directly to transgender students. The Department of Justice, Department of Education, and Department of Health and Human Services issued a joint back to school message for transgender youth.
• Outreach and education to transgender and gender diverse students and their families. The Department of Education has published fact sheets and other resources showing the federal government’s support for transgender students, highlighting the ways schools can support students, reminding schools of their duty to investigate and address harassment based on sexual orientation or gender identity, and informing students how they can assert their rights and file complaints.
• Advancing research to address the harms of so-called conversion therapy.  The Substance Abuse and Mental Health Services Administration (SAMHSA) announced that it will update its 2015 publication  Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth  to reflect the latest research and state of the field. 

Promoting fair housing and ending homelessness for transgender Americans

• Advancing fair housing protections on the basis of gender identity. In February 2021 the Department of Housing and Urban Development (HUD) announced that it would administer and enforce the Fair Housing Act to prohibit discrimination on the basis of gender identity and sexual orientation.
• Ensuring safety and access to services for transgender people experiencing homelessness. In April, HUD withdrew the previous administration’s proposed “Shelter Rule,” which would have allowed for federally funded discrimination against transgender people who seek shelter housing. By withdrawing the previous administration’s proposed rule, the agency has restored protections for transgender people to access shelter in line with their gender identity. HUD has also released new tools for recipients to ensure compliance with these requirements in shelters and other facility settings.

Advancing economic opportunity and protections for transgender workers

• Ensuring nondiscrimination protections for transgender and gender diverse workers. In November 2021, the Department of Labor’s Office of Federal Contract Compliance Programs proposed to rescind the agency’s 2020 rule “Implementing Legal Requirements Regarding the Equal Opportunity Clause’s Religious Exemption,” an important step toward protecting workers from discrimination while safeguarding principles of religious freedom.
• Ensuring equal access to the workforce development system. The Department of Labor is enforcing discrimination prohibitions in workforce development programs funded by the Workforce Innovation and Opportunity Act, protecting workers from discrimination based on their gender identity or transgender status.

Advancing gender equity and transgender equality at home and around the world

• Advancing transgender equality in U.S. foreign policy and foreign assistance. In line with the Presidential Memorandum on Advancing the Human Rights of LGBTQI+ Persons Around the World , the United States is making significant investments to uphold dignity, equality and respect for transgender persons globally.  For example, USAID supports the Global Barometer for Transgender Rights and the LGBT Global Acceptance Index which track progress and setbacks to protecting transgender lives around the world.  The Department of Health and Human Services through the United States President’s Emergency Plan for AIDS Relief supports inclusive health care services for transgender individuals, enabling health clinics to provide care to the transgender community. And through the Department of State’s Global Equality Fund , local transgender rights organizations receive support to document human rights violations and provide critical legal assistance to community members.  
• Establishing the White House Gender Policy Council to Advance Gender Equity and Equality.  President Biden signed an  Executive Order  establishing the White House Gender Policy Council to advance gender equity and equality across the whole of the government, including by addressing barriers faced by LGBTQ+ people, in particular transgender women and girls, across our country.  

Supporting transgender leaders and public servants

• Making the Federal government a model employer for transgender public servants. President Biden signed an  Executive Order  which takes historic new steps to ensure the Federal government is a model employer for all employees – including transgender, gender non-conforming, and non-binary employees. The Executive Order charges agencies with building inclusive cultures for transgender employees by: expanding the availability of gender-neutral facilities in Federal buildings; ensuring that employee services support transgender employees who wish to legally, medically or socially transition; advancing the use of non-binary gender markers and pronouns in Federal employment processes; and expanding access to gender-affirming care and inclusive health benefits.
• Appointing historic transgender leaders. The Biden-Harris Administration includes barrier-breaking LGBTQI+ leaders, including Assistant Secretary for Health Dr. Rachel Levine, who is the first openly transgender person ever confirmed by the U.S. Senate. In October, she was also named a four-star admiral in the U.S. Public Health Service Commissioned Corps, becoming the first openly transgender person to hold that rank in any of the country’s uniformed services. Over 14 percent of Biden-Harris Administration appointees identify as LGBTQI+.

Advancing visibility for transgender Americans

• Issuing the First White House Proclamation for Transgender Day of Visibility.  On March 31, 2021 President Biden became the first U.S. President to issue a  proclamation  commemorating Transgender Day of Visibility.  
• Hosting a White House Virtual Convening on Transgender Equality.  In June, White House Press Secretary Jen Psaki hosted a first-of-its-kind  national conversation  on equality for transgender, gender non-conforming, and non-binary Americans.
• Releasing a toolkit on equality and inclusion for transgender Americans.  The White House released a new  toolkit  with best practices for advancing inclusion, opportunity, and safety for transgender Americans.
• Establishing a National Pulse Memorial. On June 25, 2021, President Biden signed H.R. 49 into law to designate the National Pulse Memorial. As the President acknowledged in his statement on the fifth anniversary of the Pulse nightclub shooting, we must acknowledge gun violence’s particular impact on LGBTQ+ communities across our nation, and we must drive out hate and inequities that contribute to the epidemic of violence and murder against transgender women – especially transgender women of color. As the President has said, Pulse Nightclub is hallowed ground.

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Youth Access to Gender Affirming Care: The Federal and State Policy Landscape

Lindsey Dawson , Jennifer Kates , and MaryBeth Musumeci Published: Jun 01, 2022

This analysis reflects the policy environment as of June 2020. Our newer tracker , provides a regularly updated overview of state policy restrictions on youth access to gender affirming care.

Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.

What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?

Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.

• Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14 th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14 th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11 th Circuit.
• Arkansas . In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14 th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14 th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1 st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ  argued that the Arkansas law  violates the Equal Protection Clause of the 14 th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8 th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal. 1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs. 2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
• Texas . In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation , a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
• Arizona . In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.

In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:

• criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
• penalize parents aiding in youth accessing gender-affirming care
• permit individuals to file for damages against providers who violate such laws
• limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services

Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.

What states have introduced protections related to sexual orientation and gender identity in health care?

Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:

• prohibitions on health insurance discrimination based on sexual orientation and/or
• requirements that state Medicaid programs explicitly cover health services related to gender transition

What is federal policy regarding gender-affirming services?

The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:

• On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
• On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the  Bostock  ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.

In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:

• Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
• Statement from Dept. of Health and Human Services (HHS) Sec. Becerra : Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
• Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
• Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
• The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
• It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.

OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.

What do major medical societies say about gender affirming services?

Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association , American Academy of Pediatrics , the Endocrine Society , American Psychological Association , American Psychiatric Association , and the World Professional Association for Transgender Health , among others , which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.

Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines , as does the World Professional Association for Transgender Health’s standards of care . Together these guidelines form the standard of care for treatment of gender dysphoria.

What are the implications of access restrictions?

State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:

LGBTQ+ youth : LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy , has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.

In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.

Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.

Parents : In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.

Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.

Teachers and others : In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.

Looking forward

The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.

These states include Alabama, Alaska, Arizona, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Tennessee, Texas, Utah, and West Virginia.

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These states include California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, and Washington.

Also of Interest

• LGBT+ People’s Health and Experiences Accessing Care
• The Health System Appears To Be Selling LGBT+ People Short
• The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health