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By Orion Rummler, originally published by The 19th with funding from A-Mark Foundation.
This year, states have tried to prevent transgender people from using public bathrooms and from being able to update identity documents like driver’s licenses. Legislators in multiple states are attempting to rewrite state code to define sex based on reproductive capacity, and to exclude gender identity from discrimination protections.
So far, these bills that aim to weaken civil rights protections for trans people, and to bar them from public facilities, aren’t getting very far. Only five anti-LGBTQ+ bills have passed into law this year, according to the ACLU, and several states that have become notorious for advancing such legislation — like Florida, Utah and West Virginia — have ended their legislative sessions for the year.
Still, these efforts would have a disastrous impact on the lives of trans adults, and medical health professionals are worried about the long-term physical and mental health effects of the ongoing political effort to restrict LGBTQ+ rights. What’s more, many of the active bills would create gaps in medical care for trans people during a time of heightened anxiety.
Right now, Ashton Colby feels like he’s in a state of chronic stress. As a White, 31-year-old transgender man living near Columbus, Ohio, he felt intense whiplash as state policies on gender-affirming care changed unexpectedly over the past few months.
“With my fundamental, basic humanity being up on the public chopping block and up for debate, in so many ways, I feel gutted and dehumanized and completely misunderstood for all that I am,” he said.
Colby has been stressed for a few years about anti-trans policies. But he never thought that it would be possible for trans adults to be forced to go without medical care. In Ohio, that almost happened. Republican governor Mike DeWine proposed restricting gender-affirming care for adults in lieu of supporting a statewide ban on minors’ care; but after a public outcry, the state’s health agency said it would not carry out those adult restrictions.
Colby initially thought he was going to lose his medical provider of eight years. He considered moving to Denver. He’s also worried that his ability to access the documentation he needs — and his rights as a trans person — will be at risk if Republicans win the White House and in Congress this year.
This is something that Dr. Carl Streed, president of the U.S. Professional Association for Transgender Health (USPATH), thinks about all the time: the negative health outcomes of trans people not feeling safe while navigating society. He believes anti-trans policies will increase isolation during what the surgeon general has called an epidemic of isolation and loneliness in the United States.
“These policies that restrict peoples’ public life is effectively directly harming them, both in terms of immediate issues around mental health, connection to community, accessing care in urgent situations, but long-term, we’re going to see worse health outcomes in probably the next five, ten years, if not sooner,” he said.
What do those worse health outcomes look like? Increased isolation, and not being able to participate in public life and engage in-person with community, leads to worse cardiovascular fitness and a higher likelihood of high cholesterol and hypertension. That, in turn, creates a higher risk for heart attacks and strokes. Isolation is also associated with worse cognitive function and decreased memory, Streed said.
“They’re definitely creating quite the checkerboard of restricted public spaces,” said Streed, a primary care physician at the Boston Medical Center. “But the issue is, these are national discourses. What happens in Florida is a conversation I have with my patients in the exam room.”
It’s understandable that transgender people in states without restrictions on their healthcare or ability to access public spaces are anxious about such policies in other states, he said. The restrictions can still affect them while they’re visiting friends and family.
So far this year, the ACLU is tracking roughly 200 anti-LGBTQ+ bills that are still advancing through state legislatures — meaning these bills are active. Although many other bills have been defeated, the fear and dread within the transgender community, and much of the larger LGBTQ+ community, is still at an extreme high.
In Florida, a slew of often confusing anti-LGBTQ+ policies are meant to stoke fear, said Simone Chriss, attorney with the Southern Legal Counsel in Florida and director of the organization’s transgender rights initiative, on a press call in February.
“The intent is to create fear and to make us not understand what our rights are, so that we err on the side of caution. Vagueness and ambiguity is the point,” she said. She was speaking with assembled advocates, locals, and members of the press at an emergency “town hall” to break down the legal ramifications of — and to dispel myths about — Florida’s new driver’s license policy.
Angelique Godwin, an Afro-Latina transgender woman and advocate with Equality Florida, described to The 19th how transgender Floridians have been supporting each other in the face of mounting restrictions on daily life. Godwin lost access to her health care last spring, when Gov. Ron DeSantis signed a law preventing patients from accessing gender-affirming care from nurse practitioners. Then she wasn’t able to refill her prescription for estradiol valerate as part of her gender-affirming care, which other trans Floridians experienced as pharmacies denied patients service in the confusion following the law’s passage.
“Thankfully, I had a stash, I had my own little reserve of medications for myself. But there were people close to me that were affected by that who had no access,” she said. “It was out of nowhere for them.”
Godwin later found a facility in Tampa with a doctor who worked on a sliding-scale payment system, where she was able to continue care. She obtained coverage through the federal government’s health insurance marketplace, which helped too. And she was able to keep appointments with her regular doctor for mental health visits under the new law.
More gaps in care have been covered by mutual aid grants and by organizations like Folx Health, an LGBTQ+ telehealth provider. Folx requires an in-person doctor’s visit, where patients review and sign a consent form to obtain care in line with the state’s law.
“Those first three months from June to August, a lot of people struggled. Since then, most of the people I know that are here in Florida are still here,” she said.
Roughly 30 bills that would restrict how transgender youth and adults can access health care are still advancing through statehouses, per the ACLU. These bills would ban gender-affirming care — meaning puberty blockers and hormone therapy — for transgender youth, block insurance or Medicaid coverage for gender-affirming care, and restrict access to such care for incarcerated trans people.
Even without states passing restrictions on gender-affirming care, it is already difficult for transgender people to access it across much of the country. And for many trans people, gaining access to health care that is crucial for their wellbeing already requires travel across state lines.
Dr. Angela Rodriguez, a plastic surgeon based in San Francisco who specializes in transgender care, often works with patients who travel to California. And it’s not just because they can’t find trans-affirming care; she’s had transgender patients travel to her from Alabama, where it’s difficult to find a good dentist or primary care physician.
She’s heard a similar refrain from out-of-state patients over the last several years: Who is going to take care of them in the long run?
“I have patients that elect to come back, fly all the way from the East Coast, because they don’t feel comfortable talking to a local physician,” she said. She works with patients who travel from out of state to ensure that they have a support system, a loved one or a friend, in California who can take care of them after a surgical procedure.
Dr. Johanna Olson-Kennedy, the president-elect of USPATH who works with adolescents and young adult patients at Children’s Hospital Los Angeles, said that the mental health of her young trans patients has worsened as states ban gender-affirming care for minors. Her patients are also worried about simply existing in public in some states, and whether they can safely use public restrooms. Florida and Utah have extreme public bathroom bans in place, while eight other states ban trans people from using restrooms that match their gender identity in schools.
“I don’t think people have even really wrapped their head around the mental health burden of the pandemic, but to have this loaded on top of it is really an extraordinary lift for adolescents,” she said. Most of her patients are going on to college and graduate school — and many of them plan to avoid pursuing higher education in states that are passing anti-trans laws.
Olson-Kennedy herself doesn’t feel safe on social media. As a provider of gender-affirming care, it’s often a hostile environment for her and others in her profession, as her work has become politicized by Republican lawmakers, lobbyists and far-right media personalities.
“You can only manage a certain amount of hearing you should be shot when you leave your clinic,” she said. “That’s not something that they teach you in medical school. … This is not something that children’s hospitals or pediatricians have dealt with in the past.”
More people need to understand what gender-affirming care means, Olson-Kennedy said. The care is provided over a long period of time, with parents and guardians involved for minors, she said — and it treats the severe despair caused by gender dysphoria that many trans people feel.
“I wish that people could put aside their own discomfort and lack of understanding and just really recognize that this care is medically necessary. It’s really important, and it changes people’s lives and saves their lives,” she said.