Gender-Affirming Care: A Battleground for Health Equity and Bodily Autonomy
By Devyn Kelley (they/them) - MSW Student, UC Berkeley and Praxis Health Justice Intern - 2024 Cohort
In May of this year, I went to the hospital for a double mastectomy, an elective gender-affirming surgery that I had been waiting for for months. Even when I was still feeling the pain from the surgery, the relief that I felt from having this procedure cannot be overstated. I have a renewed sense of joy and comfort in my body and feel closer to who I am than I ever have. I feel incredibly lucky to be able to have had my top surgery and recognize that I am privileged to have had the money, time, and support to electively have a major surgery. On a personal level, this experience has been transformative and truly life-changing, but it has also affirmed for me the critical importance of fighting to protect access to gender-affirming care. In addition to many socio-economic barriers that exist for trans people trying to access gender-affirming care, our access to these vital healthcare services is under threat.
Image credit: Unsplash.com
In the past few years, LGBTQ+ people (particularly trans people) have become targets for hateful, dehumanizing rhetoric. Along with this increasing hostility has come a barrage of legislative attempts to strip LGBTQ+ people of our rights and protections against discrimination. Since 2024, over 500 bills have been introduced at the state level that target LGBTQ+ populations and many are specifically aimed at reducing access to or criminalizing gender-affirming care, particularly for youth. According to the U.S. Department of Health and Human Services, gender-affirming care is a term used to describe “an array of services that may include medical, surgical, mental health, and non-medical services” that are crucial for the health and well-being of transgender and nonbinary people. Although the term encompasses a diverse range of medical and non-medical services, political rhetoric about gender-affirming care has mostly focused on bad-faith arguments about the potentially harmful effects on children and rates of regret. Many of the state-level bills have targeted gender-affirming care for children, and the UCLA Williams Institute reports that 118,300 trans youth aged 13-17 are living in the 26 states that have passed bans on gender-affirming care. In Texas, Governor Gregg Abbott and the Texas Attorney General attempted to order the Department of Family and Protective Services to investigate cases of minors receiving gender-affirming of care as child abuse and criminalize service providers who fail to report such abuse.
Legislation targeting access to gender-affirming care has also been introduced at the federal level, which would impact thousands more gender-diverse Americans, including youth and adults. For example, Representative Marjorie Taylor Greene’s “Protect Children's Innocence Act” (H.R. 1399), aims to place a national ban on gender-affirming care for transgender and non-binary children under the age of 18. In the 2024-2025 season, the Supreme Court will hear United States v. Skrmetti, which concerns a Tennessee ban gender-affirming hormone therapy for minors, despite the fact that this kind of care is considered best practice and a tool for suicide prevention among trans youth (Attacks on Gender-Affirming and Transgender Health Care | ACP Online, 2024; Keuroghlian et al., 2022; Serchen et al., 2024). Although a majority of these legislative attacks have focused on gender-affirming care for minors, it is clear that they are part of an overarching strategy to eliminate access to gender-affirming care for adults as well. In Oklahoma, Texas, and South Carolina, bills have been introduced that aim to ban gender-affirming services for transgender people up to age 26, and several states have placed restrictions on the use of federal funds via Medicaid for gender-affirming care. In July of 2024, a federal judge blocked the enforcement of revision to the Affordable Care Act introduced by the Biden Administration that was meant to protect access to gender-affirming care for transgender Medicaid recipients. Transgender people already encounter significant barriers to accessing gender-affirming care (e.g., high costs), and attempts to obstruct access to care for Medicaid recipients only exacerbates these challenges for the most economically disadvantaged members of the trans community (Al-Hiraki et al, 2021).
The legislative attacks on gender-affirming care and corresponding anti-trans rhetoric in the media have serious impacts on the physical and mental health outcomes of trans people, and not just on those directly impacted by legislation. Speaking from personal experience, I can say that even with relatively supportive family and friends in my life, it can be difficult to resist internalizing messages that my body is wrong and that people like me shouldn’t exist. In their 2024 U.S. National Survey on the Mental Health of LGBTQ+ Young People, the Trevor Project noted that 90% of LGBTQ+ youth reported that their well-being was negatively impacted by recent politics. Even more concerning is that 39% of LGBTQ+ youth and 46% of transgender and nonbinary youth seriously considered attempting suicide in the past year, with even higher numbers among youth of color (Trevor Project, 2024). In fact, a study conducted in 2023 showed that exposure to news of anti-trans legislation was associated with “rumination and physical health symptoms” and that perceptions of support for said bills among peers provoked feelings of depression and fear to disclose one’s identity (Dhanani & Totton, 2023).
The evidence on gender-affirming care shows that access to “high-quality, gender-affirming care is an integral protective factor for the mental health and well-being” of transgender people (Restar et al, 2024). Several professional organizations have released statements of support for gender-affirming care and the American College of Physicians and other organizations have criticized attacks on gender-affirming care as interference with the physician-patient relationship. In addition to the implications of violations to bodily autonomy and patient rights, the denial of gender-affirming care is directly harmful to the physical health of trans people. The denial of this life-affirming care can include hormonal imbalances, increased risk of cancer, risk of HIV and other STIs, and an increase in suicidal ideation (Dhanani & Totton, 2023; Restar et al., 2024). Restrictions on gender-affirming care also reduces healthcare utilization overall–not just for gender-affirming services–and may cause trans people to feel forced into concealing their identities to receive care (Restar et al., 2024).
The impacts of anti-trans legislation on the health outcomes of trans people are concerning and constitute a public health crisis. However, Restar et al. (2024) note that hostile attacks against the rights of trans people are simply “malicious attempts by those in power to pit the public against a highly marginalized group and avoid addressing critical economic and social issues that affect everyone such as housing stability, infrastructure maintenance and expansion, and climate change.” The legislative attacks against gender-affirming care are also occurring alongside persistent attacks on reproductive healthcare. It is crucial to understand these concurrent threats to our access to healthcare and bodily autonomy as critical battlegrounds in the fight for health equity and justice. Protecting gender-affirming care must be on the agenda for all organizations fighting for health equity, and the voices and experiences of trans people should be leading the fight. I speak from my own experience that being able to access quality gender-affirming care was a transformative, life-altering experience that should be accessible to all transgender people regardless of income, race, and citizenship status.
Sources
Al-Hiraki, S., Nichols, S., Tran, A., & O’Connor, K. (2021). Addressing the disparities transgender patients face in the US healthcare system. Georgetown Medical Review, 5(1). https://doi.org/10.52504/001c.29779
Attacks on Gender-Affirming and Transgender Health Care | ACP Online. (2024). American College of Physicians. https://www.acponline.org/advocacy/state-health-policy/attacks-on-gender-affirming-and-transgender-health-care
Dhanani, L. Y., & Totton, R. R. (2023). Have you heard the news? The effects of exposure to news about recent transgender legislation on transgender youth and young adults. Sexuality Research and Social Policy, 20(4), 1345–1359. https://doi.org/10.1007/s13178-023-00810-6
Keuroghlian, A. S., Keatley, J., Shaikh, S., & Radix, A. E. (2022). The context, science and practice of gender-affirming care. Nature Medicine, 28(12), 2464–2467. https://doi.org/10.1038/s41591-022-02082-w
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