The Public Health Crisis State of Transgender Health Care and Policy

The rise of antitransgender legislation in the United States¹ has reached unprecedented levels. At the time of writing (October 2023), there were 574 bill proposals explicitly directed at transgender populations in 49 US states, of which 83 have been signed into law.¹ These bills aim to restrict the rights and freedoms of transgender persons, particularly children and adolescents, in areas of health care and society such as employment, education, sports, and public facilities, effectively excluding transgender persons from participating in civic life.

HEALTH IMPACTS OF ANTITRANSGENDER LEGISLATION

For instance, according to the Transgender Legislation Tracker,² of the 83 laws passed, 22 were specific to restricting access to and provision of health care (e.g., making medically endorsed best practices of gender-affirming care to minors a felony crime), 19 were aimed at education restrictions (e.g., use of pronouns, updating gender marker and name in school records, undermining the privacy of transgender status disclosure involving parents), 12 were specific to sports participation bans, and 9 were related to bathroom bans. The impact of such antitransgender policies extends far beyond legal and political spheres; it is a critical public health crisis that threatens not only access to care but also the physical and mental well-being and survival of the more than 1.6 million transgender people in the United States.³

At the core of this crisis is the deliberate denial of basic human rights and autonomy of a population for a malevolent, politically convenient, and irrational agenda. While the provision of gender affirmation (i.e., services that encompass a range of psychological, behavioral, medical, or legal interventions designed to support one’s gender identity) remains highly politicized, we, as scientific, medical, and legal communities must learn to combat the spread of disinformation and misinformation on this topic as well as policies that purposefully mischaracterize the science. The current wealth of evidence, as supported by multiple established medical organizations like the American Medical Association and the current standards of transgender health care,⁴ point to published findings indicating that high-quality, gender-affirming care is an integral protective factor for the mental health and well-being of transgender persons. This evidence also supports the view that gender-affirming care is part of bodily autonomy such that decisions are to be made only between transgender patients, providers, and parents of transgender youths—prioritizing parental consent and youths’ assent.⁴

The impact of antitransgender legislation on the mental health of transgender individuals cannot be overstated. Transgender people face significant mental health challenges because of discrimination and stigma, and the banning of gender-affirming care, in particular, can lead to trauma and other severe mental health consequences, such as suicide attempts, severe psychological distress, and depression. These outcomes are six, eight, and nine times more prevalent, respectively, in transgender populations compared with the general population in the United States.^5,6 The denial of basic rights and freedoms only exacerbates these linkages, putting transgender communities at greater risk of mental health conditions.⁶ In recent studies examining the impact of state policies, state-level antitransgender policies were significantly linked to more past-month psychological distress and endorsement of past-year suicidal thoughts, plans, and attempts among transgender adults—after adjusting for individual (e.g., demographics), interpersonal (e.g., experiences of transphobic discrimination), and social environmental (e.g., state-level inequality, religiosity as a proxy to social stigma) factors.⁷ In another recent study, state-level and city-level protective policies were linked to significantly fewer experiences of discrimination.⁸ These findings are concerning given their recency—that is, we are seeing these antitransgender policies drastically impacting mental health outcomes of transgender populations in the same year they are being introduced.

This is a crisis for public health and for mental health systems, in particular. Besides gender-affirming care itself, to our team’s knowledge, there are currently no behavioral, social, or structural interventions tailored to transgender populations that have been demonstrated to prevent or reduce adverse mental health symptoms and outcomes.^6,9 To buffer the impact of antitransgender policies nationwide, greater resources must be invested in scalable interventions to improve family support, promote social connectedness, and build transgender individuals’ and communities’ capacity for empowerment and resistance.^10,11

The physical and physiological health consequences of antitransgender legislation are equally devastating. For instance, the denial of gender-affirming care can trigger and lead to myriad adverse physical and physiological health outcomes and consequences, such as hormone imbalances, increased cancer risk, and increased risk of HIV and other sexually transmitted infections.⁶ Indeed, some states have reported a chilling effect amid the enforcement of antitransgender policies, leaving providers and mental health professionals concerned that their practices might be penalized and that their patients’ health and safety might be jeopardized.¹² Similar chilling effects have occurred in that transgender patients have hesitated to seek necessary care beyond gender-affirming care such as primary care or routine health checkups for fear of being targeted.¹² In addition, these antitransgender policies may force transgender persons who cannot flee to sanctuary states to conceal their transgender identities and disengage from lifesaving care, thus leading to unmitigated health-harming effects. These antitransgender policies can lead to increased rates of violence and victimization, too, which can result in physical injuries and trauma. As political motivations drive an antitransgender policy landscape, public sentiment follows, emboldening hate groups and dangerous subpopulations in society who wish to eradicate transgender people.

PUBLIC HEALTH ROLES AND EVIDENCE-BASED SOLUTIONS

We have at our disposal the ability and tools across scientific, medical, and legal armamentaria to proactively curb the impact of this legislation on the mental and physical health outcomes in transgender populations, and even dismantle the oppressive systems that uphold and reinforce these policies.¹³ Strategic responses require us first to repair and heal relationships of historical distrust between transgender communities and scientific and medical communities. Forming meaningful collaborations and partnerships between transgender communities, stakeholders, and researchers entails establishing equitable team structures. These collaborative teams should prioritize transgender researchers and stakeholders as leaders in decision-making processes—while simultaneously being proactive in allyship, particularly those of us in leadership positions who are in power to amplify key and informed public health messages to make lasting changes.

Investing in community-engaged and community-led research, programs, and policy initiatives (e.g., the Trans Legislation Tracker, Center for Applied Trans Studies) is also crucial to ensure that such responses are community-driven and that they saliently address pressing health and legal needs and directly benefit transgender communities.^2,13 In addition, it is important to collaborate with other health equity scholars exploring and expanding concepts and strategies on resilience, racial equity, disability rights, Indigenous well-being, and reproductive health, among other topics, given the intertwining impacts of transgender health and policies in these areas,¹³ and that health and legal professionals will also encounter transgender people among their target population.

Increased investments in rigorous research methodologies are necessary to strengthen evidence, address research and policy gaps, and combat misinformation. Specifically, these investments can begin with federal, state, and privately funded epidemiological studies or national surveys with gender-inclusive and gender-specific approaches that recognize and distinguish the health needs of all gender groups, longitudinal cohort studies that comprehensively map the impact of structural factors like protected policies on health, and interventions and clinical trials that are scalable and community-driven. These methodological and structural strategies can advance our responses and promote practices that are not only equitable but also just, on a larger scale.

Antitransgender policies reflect 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 (e.g., housing stability, infrastructure maintenance and expansion, climate change). The epidemic of antitransgender policies aims to regress decades of medical, public health, and policy progress, placing our achievements at a perilous crossroads. Where there is legislation that restricts a specific population’s lives and human rights, there are multiple negative and inequitable consequences—as with the case of banning abortion rights, adverse birth outcomes and increased mortality were a consequence.¹⁴ Respect for privacy, bodily autonomy, and the preservation of human rights for transgender people must be core ethical components of current and future health policies, and communities of medical, public health, and policy professionals must proactively oppose legislation that undermines public health responses. These actions are necessary components to achieving health equity for all.