June is Pride Month.
By the time she was 12 years old, Erin Reed knew she was transgender. But the Louisiana native didn’t have access to the medical care she needed to transition, so it would be another 17 years before medical intervention would allow her to feel at home in her body.
“I went through a long period of trauma associated with hiding who I am,” said Reed, a transgender activist who is now 34. That trauma led to more than a decade of crippling anxiety and panic attacks that resolved after she transitioned. “In the years following my transition, I have been overjoyed, healthy and happy — everything that I wanted to get from this, I got and more.”
Now, Reed lives in Maryland, a state whose governor recently declared it a sanctuary for transgender people, and she has a team of healthcare providers (HCPs) who understand her as a trans woman and provide her with gender-affirming healthcare she needs — a luxury for many in the LGBTQ community.
Gender-affirming care refers to a broad range of medical and non-medical services designed to help someone transition their gender, which means transitioning from the gender they were assigned at birth to the gender that matches their gender identity.
Gender-affirming care can include hormone therapy or surgery. But it also refers to healthcare that is provided in an accepting way no matter how the patient identifies. That can be as simple as HCPs asking for and using preferred pronouns to being informed and experienced in treating transgender people.
“For transgender patients who have historically and contemporarily been discriminated against within the healthcare setting, gender-affirming care means having a provider who respects and celebrates who they are,” said Sarah Pickle, M.D., associate professor of clinical family and community medicine at the University of Cincinnati College of Medicine. “For some people, that could mean allowing their body to be aligned through hormone therapy or other medical or surgical interventions.”
Pickle helped develop UC’s transgender medicine curriculum, which is integrated throughout the general medical curriculum. “Just like our cisgender patients [people whose gender identity matches their sex assigned at birth], our transgender patients are represented in the patient stories, the clinical vignettes and the teaching that our medical students are going to have.”
Getting gender-affirming care can be the difference between life and death. Research shows that 8 out of 10 transgender youth have considered suicide — and 4 out of 10 have followed through with an attempt. Gender dysphoria — when your gender identity does not match your assigned sex — can cause severe emotional distress. But when people’s physical bodies match who they know they are, depression and anxiety may be less severe, and self-esteem, self-acceptance and confidence improve.
According to a 2022 study, gender-affirming care, including puberty blockers and hormone therapy, makes an enormous difference in trans people’s mental health. In fact, having gender-affirming care lowers the odds of depression by 60% and the odds of suicide by 73%.
“If somebody has a marginalized identity, and they are in a chronic state of societal stigma and discrimination and have less access to medical care to improve other aspects of their health, [it puts their body under] chronic stress,” Pickle said. “It’s going to lead to poorer mental and physical health outcomes.”
In one survey, nearly 1 in 4 transgender people reported not seeking out healthcare when they needed it (even when it was unrelated to transitioning) out of fear that they would be mistreated by their HCP.
“It was really scary going to the doctor my first six months after transitioning,” Reed said. She was nervous about how she would be perceived and how healthcare providers would treat her.
And the fear is rational: About 1 in 3 transgender people who did see a HCP reported having a negative experience, such as harassment or being refused treatment because of their gender identity
“Sometimes it is very explicit that people are being mistreated because they are transgender,” Pickle said. “People are asked inappropriate questions or even forced to have inappropriate examinations out of providers’ lack of cultural competency in this area and often because of transphobia. Then there’s this more implicit discrimination that can happen that often is from lack of knowledge, lack of training and lack of experience across the healthcare field.”
More than 146,000 young people in the U.S. have already lost or are at risk of losing access to gender-affirming care.
So far this year, more than 125 bills have been introduced to ban or limit gender-affirming care, including one in Ohio, where Pickle practices. Nineteen states have already passed legislation restricting gender-affirming care, going so far as to punish health providers with jail time if they treat minors. In response, 11 states and the District of Columbia have passed laws or signed executive orders protecting access to gender-affirming care.
Critics of gender-affirming care argue that supporting minors in transitioning is child abuse, and that children should wait until they are adults to avoid later regrets. However, a 2021 review of studies found that only about 1% of teens who transitioned regretted their decision.
“Gender-affirming care is medical care, period,” Reed said. “It’s directed by teams of doctors, psychologists and parents … and taking away access actually prevents parents from helping their kids get the care they need.”
Pickle said laws that ban gender-affirming care have far-reaching consequences for how HCPs interact with their patients.
“In general, these laws that are trying to prevent medically necessary, evidence-based care really fracture the patient and physician relationship,” she explained.
Many of Pickle’s students and patients are terrified, and the bans have affected where her students decide to practice — ultimately leading to fewer HCPs with knowledge and experience with trans issues in conservative states. It’s an issue, she says, that should be important to people beyond the transgender community.
“Think about anybody that you care about with a health condition who is getting great care from their physicians and they’re thriving. Then, all of a sudden — even though that care is based on good evidence and there are studies to support it, and people are doing well — somebody tells you your loved one can’t access that care anymore. It’s devastating.”
Reed points out that the same states banning gender-affirming care for transgender people are denying reproductive rights to women with extremely restrictive abortion bans, and that the parallels are striking.
“These laws that ban essential healthcare for trans people, they’re not divorced from laws that are targeting other forms of healthcare as well,” Reed said. “There are ‘abortion refugees’ who leave their home states to seek care because their abortions are criminalized, and trans people fleeing those same states because their basic healthcare is criminalized.”
Ultimately, she said, laws banning abortion and gender-affirming care are violating human rights, and both will have huge consequences for communities and individuals.
“It’s all anti-science and anti-bodily autonomy,” she said.