Understanding and Addressing Disinformation in Gender-Affirming Health Care Bans

Abstract

Legislation undermining the human rights of transgender and gender-expansive (TGE) people is on the rise. Many U.S. states have passed or proposed laws that restrict gender-affirming health care (GAC), which are largely rooted in scientific disinformation, meaning intentional falsehood. Scientific disinformation presents a significant threat to TGE people, providers of GAC, health care professionals, and the general public. Clinicians, legal advocates, and others need effective strategies to rebut disinformation. This perspective reviews the status of GAC bans and the disinformation strategies that underlie them, and provides practical tools to challenge false claims.

Introduction

In recent years, 19 American states have passed laws that deny social dignity and inclusion to transgender and gender-expansive (TGE) adolescents.¹ The most brazen of these policy actions ban gender-affirming health care (GAC) and are based on scientific disinformation, meaning information that is false and intended to mislead.^2,3 TGE youth and their caregivers face a new responsibility to defend their physical safety and personhood against baseless claims codified into law. Family members, health care providers, and other supportive individuals are uniquely situated to dispel disinformation. This perspective is a review of the current legal landscape surrounding GAC bans, the strategies that underlie them, and tangible tools to challenge them.

The status of GAC bans in the United States

Since late 2021, a cascade of GAC bans has unfolded in Arkansas, Texas, Alabama, Arizona, and Florida.^2–9 As of October 2022, three of these bans have been blocked by preliminary injunctions, reflecting judicial skepticism about their legality. In the coming months, federal courts will decide whether to continue blocking enforcement of the GAC bans in Arkansas and Alabama, while state court litigation in Texas is also ongoing. However, efforts to ban GAC continue. The Florida Boards of Medicine and Osteopathic Medicine recently proposed a measure to ban the provision of GAC for minors who are not already engaged in treatment. Across these states, punishments for not adhering to these bans range from loss of licensure to imprisonment for clinicians and other supportive individuals.

What is at stake

GAC is the only evidence-based treatment for gender dysphoria, a condition that reflects a discordance between one's gender identity and sex assigned at birth. GAC is a process that may include social transition, connection to community supports, mental health care, and medical treatments according to clinical practice guidelines.^10,11 GAC is not a linear process, and the needs of TGE people are diverse. One's pursuit of gender affirmation may or may not include medical interventions. The scientific evidence shows that GAC is lifesaving care that improves mental health and physical well-being in those experiencing gender dysphoria. GAC for youth and adults has been expressly supported by over 20 major medical associations.¹²

For TGE youth, care is facilitated by a multidisciplinary team of health care providers, who consult with patients and guardians about measures ranging from social transition to medication, depending on the patient's needs. Such care is longitudinal and legal guardians must provide consent for all medical therapies.

Up to 98,050 TGE youth reside in jurisdictions of emerging health care bans.¹³ When evidence-based care of gender dysphoria is interrupted or restricted, suicide, depression, anxiety, disordered eating, and poor quality of life may follow.^14–19 Such bans also dehumanize TGE youth during a pivotal period of development. Legal actions inflame minority stress by broadcasting a message of nonaffirmation and prejudice. The law's amplification of external stressors while undermining family and school-based support systems inflict multidimensional harms on TGE youth. In the past year, nearly 19% TGE youth reported suicide attempts, 53% reported seriously considering suicide, and over 90% reported fears of losing access to medical care and public bathrooms.²⁰

GAC bans also have wider implications for privacy, bodily autonomy, and the integrity of evidence-based medicine. These bans intrude into the doctor–patient relationship and medical decision making. They also issue harsh punishments toward clinicians who seek to act ethically by providing standard medical care.^2,3 The adoption of GAC bans based on disinformation also distorts public opinion and may degrade trust in health care.²¹

Engaging with disinformation about gender dysphoria and GAC

Four themes of disinformation emerge from the policy documents that justify GAC bans, including false claims about (1) gender dysphoria and TGE identities, (2) the evidence supporting GAC, (3) standard practice of GAC, and (4) the safety of gender-affirming medical treatments.^2,3

Proponents of GAC bans propagate disinformation in a few predictable ways. They include testimony and publications by purported “experts,” many of whom have no clinical or research experience in GAC, have ties to antitransgender organizations or whose testimony has previously been excluded by judges.^2–4 They also operate by omission, ignoring the preponderance of evidence on GAC and the contents of clinical practice guidelines developed by internationally recognized medical societies.^2,3

Rebutting disinformation about GAC is critical to protecting TGE people and the integrity of health care, but many may not know how. Table 1 outlines strategies for countering specific claims associated with each disinformation theme, with evidence cited from systematic reviews and other robust studies. Parallel examples of standard medical care that does not face legal embargo can illustrate the discriminatory exceptionalism to which GAC is subject. Allies of TGE youth may find these points useful in their communities, institutions, media engagement, and beyond. The “truth sandwich” model offers a useful structure for correcting falsehoods: lead with the truth, briefly describe the falsehood, then fact-check the misinformation and repeat the truth.²²

Table 1.

Using the Evidence to Rebut Disinformation About Gender-Affirming Care

Theme	False claim	Rebuttal arguments, supporting evidence, and examples
False claims about gender dysphoria	Social contagion is responsible for increasing numbers of TGE youth.	Currently known rates of youth identifying as TGE fall between 1% and 2%, although recent studies have noted higher rates (7–9%) when using a two-step method to assess gender identity, where participants are asked about their sex assigned at birth, and subsequently asked about their gender identity.23,24 A single study concluded that social contagion may influence gender identity, based on parental report rather than direct study of TGE youth.29 Its findings have not been replicated and this article was subject to heavy correction.30 Before recent legislative actions, TGE individuals may have felt safer in expressing their gender identities with the emergence of mainstream affirming language to explain their experiences of gender expansiveness. If TGE identities were “spread” through social contagion, the rates of youth identifying as TGE would likely be much higher than currently reported.
	Gender dysphoria is a mental illness that should be treated with psychotherapy alone.	Gender dysphoria has been depathologized by the American Psychiatric Association and the World Health Organization.25,26 There is no mental health disorder of which a transgender or gender-expansive identity is a symptom or part of diagnostic criteria. Medical aspects of gender-affirming care have demonstrated independent beneficial effects in studies that controlled for the effects of psychotherapy and psychotropic medications.19,27,43,44 Conversion therapies have been proven to be harmful and inherently pathologize the gender identities of TGE youth.19,28
	Most youth with gender dysphoria will change their minds and revert to identifying with the sex they were assigned at birth, otherwise termed “desistance.”	Previously published studies suggesting high rates of so-called “desistance” utilized inclusion criteria that encompassed gender-nonconforming behaviors without gender dysphoria, and included symptoms of Gender Identity Disorder, an outdated diagnosis that was removed from the DSM-5. These studies also counted youth who did not want medical aspects of transition and those lost to follow-up as “desisters.”29–31 In recent larger studies, rates of change in gender identity are very few.31–33 In a 5-year prospective study of TGE children, 93% reported no change in their gender identity and 97.5% continued to identify as TGE.33
	Most people who transition experience regret and detransition.	The vast majority of those who undergo any form of gender transition do not regret their medical decision making.34 Regarding surgeries of any kind, a recent systematic review found that rates of regret for TGE patients was around 1%, with a pooled total of 7928 patients across 27 studies.35,36 Post-treatment decisional regret occurs in varying degrees throughout health care. Rates of regret regarding other medical procedures, such as breast augmentation, breast reconstruction, adolescent scoliosis surgery, and others are far higher.35 Among cisgender women who underwent breast reconstruction surgery, ∼20% reported postprocedure regret, yet there is no legal embargo on postmastectomy breast reconstruction.36–38 Alongside guardians' consent for medical treatments, youth autonomy is recognized. The standard of care is that a minor's assent be accompanied by awareness and acceptance of the risk of post-treatment regret. Limiting health care based on the possibility of future regret supposes that a patient is not making an informed decision despite sound processes, which violates the ethical principle of autonomy.
False claims about the evidence.	There is no evidence of the benefits of GAC.	GAC improves a variety of outcomes in those experiencing gender dysphoria, including improved mental health outcomes, particularly with regard to depression, anxiety, nonsuicidal self-injury, suicidal ideation, eating disorders, and body satisfaction.19,40–45 TGE individuals avoid seeking care from health systems in which they fear discriminatory treatment.45 Those who receive GAC may feel more comfortable engaging in other aspects of health care.57
	Studies that show GAC improves mental health are confounded by psychotherapy and other supportive services.	The first studies on the efficacy of gender-affirming medications were not designed assess the independent effect of gender-affirming medications on mental health and they make no such claims.41,42 Subsequent research demonstrated the mental health benefits in larger samples, with control groups and with analysis that controlled for other mental health treatments.10,27,43
	Studies on gender dysphoria and GAC have only generated “low-quality” evidence.	Some medical organizations, like the Endocrine Society, develop guidelines using systematic processes that select and review scientific evidence, then rate the quality of that evidence and grade the strength of recommendations that follow. “Low quality” is a specific term that describes evidence from observational study, and often leads to strong recommendations for clinical practice.58 Clinical practice guidelines in obesity recommend that children consume fruits and vegetables rather than sweetened beverages such as juice, which is based on “low-quality evidence.”54 Reye syndrome is a mysterious neurodegenerative disorder associated with aspirin use in febrile children, which has spurred recommendations on aspirin avoidance based on “very-low-quality evidence.”58
	Gender-affirming care is experimental.	The first use of exogenous sex hormones for gender-affirming purposes dates to the 1930s when estrogen and testosterone first became commercially available. The first mention of puberty blockers in the medical literature for gender dysphoria was in 1988. As of 2022, more than 15 studies have established that GAC is safe and effective. Prospective studies of gender-affirming medical treatments with federal funding are under way.
	RCTs are needed to establish the safety and efficacy of GAC. Observational data alone are insufficient.	Ethical concerns and logistical impracticalities limit the utility of RCTs in studying GAC. Randomization to no treatment is unethical, as the benefits of GAC are well established, and it is impossible because the effects of placebo versus treatment would be readily detectable by patients and providers. Furthermore, narrow allegiance to RCTs would lead to massive disruptions in standard medical care. Observational data informed the use of statins, penicillin, insulin, mammography, and some minimally invasive surgeries.53
False claims about the standard of care	Medical interventions are provided to prepubertal children.	Clinical practice guidelines explicitly state that prepubertal children are not eligible to receive medical aspects of GAC.10,11
	Genital surgery is performed before the age of majority.	Criteria for surgery for adolescents exist to assess a youth's capacity to assent to surgery and for youth and legal guardians to understand/have access to information about the long-term implications of procedures.10 The standards of care state that gender-affirming genital surgery should not be performed before the age of majority to ensure that all patients can legally provide independent consent for these procedures.10
	Care is rushed and clinicians have an agenda to push a medicalized transition.	A rushed, medicalized gender transition is not possible under the current standards of care.10 These standards include a thorough assessment and evaluation, consultation, and collaborative care. Furthermore, consent for all aspects of gender-affirming medical care for a minor must be provided by legal guardian(s).
	Those below the legal age of majority are expected to give consent.	Consent is given by guardians, not minors. Minors assent, meaning they assert their bodily autonomy by agreeing to or refusing care. Both consent and assent are critical components of decision making. Legal minors do not unilaterally consent to medical care.
False claims about the safety of GAC	Medical treatments have not received approval from the U.S. FDA for gender-affirming purposes, and thus, are experimental or unsafe.	The term “off-label” refers to the use of any treatment that has not received FDA approval for the specific purposes for which it is being used. Many medications do not receive FDA approval for pediatric use because it is difficult to conduct the necessary research in such populations. Off-label use of GAC medications is legal, safe, and evidence-based.10,11 Up to 30% of prescriptions written in pediatric settings are off-label.47 Notable examples include oral contraception to treat pain associated with menses, endometriosis, or heavy menstrual bleeding, steroids for croup in toddlers, and proton-pump inhibitors in infants with gastroesophageal reflux.
	Puberty blockers have permanent and harmful effects on fertility, bone mineral density, and cognition.	The safe use of gonadotropin-releasing hormone agonists in youth was established in the treatment of precocious puberty.48,50 Their effects on fertility and bone mineral density are reversible. There is no current evidence to suggest that puberty blockers adversely affect cognitive development. Bone mineral density in adolescents is also affected by medical treatments such as systemic steroids (uses include asthma and autoimmune disorders) and Depo-Provera for contraception.51,52
	Medications have harmful and dangerous effects, such as venous thromboembolism, heart disease, and breast cancer.	Studies in adults have established that those who receive gender-affirming medications do not experience higher rates of adverse health outcomes.54,55 These studies established that risks of breast cancer among transgender women are comparable to those among cisgender women. Risks of MI among transgender men are higher than among cisgender women but less than those of cisgender men. There is no robust evidence to demonstrate that TGE individuals receiving GAC are at disproportionately high risk of mortality due to breast cancer or MI.

FDA, Food and Drug Administration; GAC, gender-affirming health care; MI, myocardial infarction; RCT, randomized controlled trial; RCTs, randomized controlled trials; TGE, transgender and gender expansive.

Theme 1: False claims about gender dysphoria

Proponents of GAC bans wrongly deny the existence of gender dysphoria, attributing this condition to social contagion and mental illness.^23–29 These assertions are without scientific merit. Table 1 describes updated evidence regarding so-called regret and desistance and how these data compare to other aspects of health care.^30–38

Theme 2: False claims about the strength of evidence

GAC is effective, beneficial, and supported by decades of robust research.^{10,11,39–44} Clinical practice guidelines for GAC are periodically revised by experts to reflect the best science.^10,11 And yet, policymakers defending GAC bans claim that there is “no evidence” to support GAC or that GAC is “experimental.”³ In Table 1, rebuttals are offered for subthemes of these false claims.

Theme 3: False claims about the standard practice of GAC

Clinical practice guidelines describe a careful, staged process of informed consent involving parents and a multidisciplinary health care team.^10,11 Like any medical care, GAC is tailored to the needs of each patient, and there is no lockstep protocol. No medical interventions are offered before the onset of puberty. However, disinformation about standards of care and current practice treat GAC as a medicalized conveyer belt. Table 1 offers an accurate account of standard practices to provide the reader with rebuttal arguments to false claims.

Theme 4: False claims about the safety of GAC

GAC is safe, well-tolerated, and offers benefits that, for many, outweigh risks.^10,11 Table 1 focuses on gender-affirming medications, specifically puberty blockers and exogenous sex hormones and draws parallels between GAC and other aspects of health care.^46–52 Generally speaking, an individual's use of estrogen or testosterone does not incur higher health risks than those they would incur if they had been assigned that sex at birth.^53,54 Disinformation claims embedded in legal language have portrayed GAC as dangerous and risky.

Conclusion

Proactive strategies must accompany the rebuttal of disinformation. True experts can correct the public record by providing testimony, written comments, and media engagement. This strategy may be of particular interest to investigators whose work has been misused in the language of GAC bans.

Medical and legal collaboration has proved successful in challenging GAC bans in litigation. Professional societies have been influential in expressing the scientific consensus through amicus briefs and position statements.¹² Rebuttal reports by medical and legal subject matter experts have exposed disinformation and provided substrate to lawyers representing plaintiffs who seek to challenge such bans.^2,3,55,56 Members of professional societies can encourage organizational leadership to update position statements and condemn disinformation explicitly.

We may also consider more concerted efforts to showcase the long-term benefits of gender-affirming care. Further research on the positive experiences of TGE youth may counteract negative stereotypes and be of high value in advocating for expansion of services. Clinical investigators should continue to seek federal support for their work in GAC and receive similar investment as other standard medical care.

Abbreviations Used

FDA

Food and Drug Administration

GAC

gender-affirming health care

MI

myocardial infarction

RCT

randomized controlled trial

TGE

transgender and gender expansive

Authors' Contributions

N.G.M.: Conceptualization and writing—original draft preparation. C.L.: Conceptualization, and writing—original draft preparation. C.L.O.: Supervision, wand riting—reviewing and editing. M.M.: Conceptualization, supervision, and writing—reviewing and editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Meade NG, Lepore C, Olezeski CL, McNamara M (2023) Understanding and addressing disinformation in gender-affirming health care bans, Transgender Health 9:4, 281–287, DOI: 10.1089/trgh.2022.0198.