Statement on the Politicization of Gender-Affirming Care and Threats of ‎Violence Against Clinicians ‎

April 20, 2023

The Society for Adolescent Health and Medicine (SAHM) opposes discriminatory legislation prohibiting transgender and gender-diverse (TGD) adolescents and young adults (AYAs) and their families, from receiving needed care, and condemns harassment of clinicians, programs, and institutions.  Discrimination and violence against transgender individuals, including AYAs, occurs worldwide.[1] A number of countries have enacted laws criminalizing gender expression that harm transgender youth [2,3]. At this time, in the United States (US) states are enacting bans on gender-affirming care for adolescents and health care providers are experiencing harassment and threats of violence. This statement speaks to the harmful policy environment and inflammatory rhetoric in the US and expresses support for access to gender-affirming care and the safety of clinicians worldwide.

Harms to TGD AYAs and Families

In the US, an estimated 300,000 (1.4%) adolescents aged 13-17 years and an estimated 400,000 (1.3%) of young adults age 18-24 years identify as TGD [4]. Global estimates suggest  0.3 to 0.5% of adults and 1.2 to 2.7% of children and adolescents are transgender[5].  Many national and international medical organizations recommend patient-centered, specialized, interdisciplinary, gender-affirming medical care that aligns with the goals, values, beliefs, and preferences of TGD AYAs and their families [6-8].

Growing evidence suggests improved physical and mental health outcomes when AYAs with gender incongruence receive gender-affirming treatment [7,9-12]. Pubertal suppression can prevent further development of irreversible and psychologically distressing changes associated with biological puberty [7,9,10]. For older AYAs, gender-affirming hormone therapy with estradiol or testosterone can induce secondary sex characteristics consistent with their gender identity and is associated with improved quality of life and mental health [7,9-12].

In the US, gender-affirming care is highly politicized [13]. State lawmakers have introduced hundreds of bills hostile to TGD people; many already enacted would explicitly limit access of TGD adolescent minors to gender-affirming care, bar health insurers from providing coverage, and threaten clinicians’ ability to maintain licensure required for clinical practice [13,14,15].

TGD AYAs and their families in the US have spoken about stress and uncertainty created by threats to gender-affirming care and the adverse effects of anti-transgender legislation,  the deleterious impact on mental health, increased stigma, decreased safety, and potential legal risks [17,18]. When gender-affirming care is defined as child abuse, parents confront choosing between supporting their children accessing care or denying care to protect their families from potential investigation, separation, and criminal penalties. Many families are considering relocating for their protection to states where access has not been curtailed[16]. In a Trevor Project poll of LGBTQ youth, 85% of participants reported that the debate about anti-transgender legislation has negatively impacted their health [19].

Legislative bans also disproportionately impact TGD youth from minoritized backgrounds and communities of color who cannot travel or relocate for care [20]. These laws may worsen preexisting health disparities by race, ethnicity, and socioeconomic status. In the US, legal restrictions on access to, and third-party payments for, gender-affirming care may increase the likelihood of patients turning to unofficial and potentially dangerous sources for vital medications.

Harms to Clinicians and Health Care Facilities

Anti-TGD rhetoric, discriminatory legislation, and restrictive policies negatively impact and hinder the work of clinicians who deliver gender-affirming care. Gender-affirming care programs have closed or face closure [16]. In a recent survey in the US, gender-affirming care providers expressed concern that the politicization of gender-affirming care would limit the ability of clinicians to practice in accordance with evidence-based standards [22]. Clinicians practicing in restrictive US states must decide between providing care and risking legal sanctions or denying patients’ and families’ rights to care [22,23]. Clinicians also report that time and effort directed towards safeguarding their practices has detracted from providing potentially lifesaving care. Moreover, clinicians express worry that restrictive legislation could affect health insurance coverage for gender-affirming care harming patients otherwise unable to afford care [24]. Some clinicians have considered relocating to states that do not currently restrict their ability to provide care, citing professional, legal, and personal risk [22].

Clinicians and health care centers also have been direct targets of organized misinformation and harassment campaigns, including protests at practices, attempts to disrupt clinical services, and threats against staff lives and safety [25]. Politicians and extremist influencers have targeted children’s hospitals and individual clinicians with disinformation and inflammatory rhetoric on social media [26,27,28]. Some campaigns have published individual clinicians’ phone numbers and home addresses on the internet and have even “swatted” providers (falsely reporting a violent crime to elicit law enforcement response) [26].

Restrictive legislation and targeted harassment only further stigmatize TGD adolescents and their families, leading to poorer access to care and worse health outcomes. SAHM calls on institutional leaders and health professionals to do all within their power to support TGD AYAs, their families, and the clinicians who serve them and to:

1. Ensure TGD AYAs have access to gender-affirming care by opposing restrictive laws and policies, coercive tactics, and targeted harassment campaigns that obstruct care and by educating stakeholders and policymakers on the evidence supporting gender-affirming care and the centrality of AYAs and their families in making informed health decisions.

2. Support clinicians who provide gender-affirming care by affirming health system-level commitments to care for TGD AYAs and their families, providing accurate information on gender-affirming care, using multiple platforms to battle misinformation, opposing the targeted harassment and intimidation of clinicians who provide gender-affirming care, and ensuring the safety of clinicians and clinical programs,

3. Mobilize, organize, and engage community members to hold elected officials accountable for policies that undermine diversity, equity, and inclusion, and that are contrary to evidence-based care; to expose lawmakers’ coercive tactics forced upon clinicians, health systems, and insurers; and to support legal protections for access to medically necessary gender-affirming care.

4. Call on governmental agencies to protect access to gender-affirming care by implementing prohibitions against discrimination based on gender identity and sexual orientation.

5. Call on policymakers to enact and implement protections to safeguard the professional careers and personal security of clinicians who provide gender-affirming care and their families and loved ones.

References
[1]    Rights in Transition: Making Legal Recognition for Transgender People a Global Priority. Human Rights Watch, 2016. Available at https://www.hrw.org/world-report/2016/country-chapters/africa-americas-asia-europe/central-asia-middle-east/north-0.
[2]    #Outlawed. “The Love that Dare Not Speak Its Name,” LGBT Rights, Human Rights Watch.
Available at https://internap.hrw.org/features/features/lgbt_laws/.
[3]    Russian Legislation Threatens Vulnerable Populations. WPATH, 2020. Available at
https://www.wpath.org/
[4]        Herman JL, Flores AR, O’Neill KK. How Many Adults and Youth Identify as Transgender in the United States? Available at: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Pop-Update-Jun-2022.pdf.
[5]    Zhang Q, Goodman M, Adams N, et al. Epidemiological Considerations in Transgender
Health: A Systematic Review with Focus on Higher Quality Data. International Journal of
Transgender Health 2020;21:125-137.
[6]        Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health 2022;23:S1–259.
[7]        Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism 2017;102:3869–903.
[8]        Hsieh S, Leininger J. Resource List: Clinical Care Programs for Gender-Nonconforming Children and Adolescents. Pediatr Ann 2014;43:238–44.
[9]        Spack NP. Management of transgenderism. JAMA 2013;309:478–84.
[10]      Rafferty J, Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence, et al. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics 2018;142:e20182162.
[11]      Connolly MD, Zervos MJ, Barone CJ, et al. The Mental Health of Transgender Youth: Advances in Understanding. Journal of Adolescent Health 2016;59:489–95.
[12]      de Vries ALC, McGuire JK, Steensma TD, et al. Young Adult Psychological Outcome After  [fix]
[13]      Conron K.J., O’Neill K.K., Vasquez L.A., et al. Prohibiting Gender-Affirming Medical Care for Youth. Available at: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Youth-Health-Bans-Mar-2022.pdf.
[14]      Berg-Brousseau H. ICYMI: Top Lawmakers Leading the Fight Against Anti-LGBTQ+ Bills in TX, AL, FL, KY, KS, and TN Underscore Urgency on the National Crisis Brewing in States, Preview the Path Forward for LGBTQ+ People. Available at: https://www.hrc.org/press-releases/icymi-top-lawmakers-leading-the-fight-against-anti-lgbtq-bills-in-tx-al-fl-ky-ks-and-tn-underscore-urgency-on-the-national-crisis-brewing-in-states-preview-the-path-forward-for-lgbtq-people.
[15]      Florida Board of Medicine, Standards of Practice for the Treatment of Gender Dysphoria in Minors, FAC 64B8-9.019, 2022 FL Regulation Text 49389, adopted Feb. 24, 2023.
[16]      Carlisle M. As Texas Targets Trans Youth, a Family Leaves in Search of a Better Future. Available at: https://time.com/6196617/trans-kids-texas-leave/.
[17]      Abreu RL, Sostre JP, Gonzalez KA, et al. Impact of gender-affirming care bans on transgender and gender diverse youth: Parental figures’ perspective. Journal of Family Psychology 2022;36:643–52.
[18]  The Trevor Project: 2022 National Survey on LGBTQ Youth Mental Health. Available at
https://www.thetrevorproject.org/survey-2022/
[19]      The Trevor Project. Issues Impacting LGBTQ Youth. Available at: https://www.thetrevorproject.org/wp-content/uploads/2022/01/TrevorProject_Public1.pdf.
[20]      Button P, Dils E, Harrell B, et al. Gender Identity, Race, and Ethnicity Discrimination in Access to Mental Health Care: Preliminary Evidence from a Multi-Wave Audit Field Experiment. Cambridge, MA: National Bureau of Economic Research; 2020.
[21]      Lett E, Abrams MP, Gold A, et al. Ethnoracial inequities in access to gender-affirming mental health care and psychological distress among transgender adults. Soc Psychiatry Psychiatr Epidemiol 2022;57:963–71.
[22]      Hughes LD, Kidd KM, Gamarel KE, et al. “These Laws Will Be Devastating”: Provider Perspectives on Legislation Banning Gender-Affirming Care for Transgender Adolescents. Journal of Adolescent Health 2021;69:976–82.
[23]      Dawn L, Kates J, Musumeci M. Youth Access to Gender Affirming Care: The Federal and State Policy Landscape. Available at: https://www.kff.org/other/issue-brief/youth-access-to-gender-affirming-care-the-federal-and-state-policy-landscape/.
[24]  National LGBTQ Task Force. New Analysis Shows Startling Levels of Discrimination
Against Black Transgender People. Available at: https://www.thetaskforce.org/new
-analysis-shows-startling-levels-of-discrimination-against-black-transgender-people/..
[25]  Das RK, Ganor O, Drolet BC. Addressing online extremism — lessons from current threats
to gender-affirming care. JAMA Pediatrics 2023;177:329-30.
[26]      Carlisle M. Pediatricians Who Serve Trans Youth Face Increasing Harassment. Lifesaving Care Could Be on the Line. Available at: https://time.com/6146269/doctors-trans-youth-gender-affirming-care-harassment/.
[27]      Sy S. Children’s hospitals become targets of anti-transgender attacks and harassment. Available at: https://www.pbs.org/newshour/show/childrens-hospitals-become-targets-of-anti-transgender-attacks-and-harassment.
[28]      Shouse California Law Group. “911 Prank Call” – Can I go to jail for making one? Available at: https://www.shouselaw.com/ca/blog/911-prank-call/.

 

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