Abstract
Objectives. To document transgender Floridians’ service needs before and after antitransgender state legislation.
Methods. We conducted descriptive and change point analyses of intake survey data collected by a transgender-led community-based organization in Florida from 701 clients who requested services between 2018 and 2024.
Results. Findings show enrollment for services increased during the rise in antitransgender legislation, with pressing needs for legal and financial support for name changes and gender-affirming health care. The percentage of clients requesting sexual health resources increased, especially among Black clients.
Conclusions. Findings underscore the urgency of (1) understanding the impact of antitransgender legislation on service needs, and (2) understanding the sequelae, including the ability for organizations to meet needs and the impact on psychosocial health outcomes. Findings emphasize the crucial role of community-based organizations in supporting transgender people in a discriminatory environment and generating data to inform policy.
Public Health Implications. Antitransgender legislation constitutes a public health crisis by restricting life-saving care and exacerbating health disparities. Community-based organizations can resist these laws and act as a protective buffer for affected individuals. (Am J Public Health. 2025;115(10):1642–1651. https://doi.org/10.2105/AJPH.2025.308171)
Discrimination is a social determinant of health, especially for transgender people (people are transgender if they experience incongruence between gender identity and gender assigned at birth).1–3 Transphobia interacts with other forms of discrimination (e.g., racism, sexism, homophobia), including legal discrimination enacted through legislation, and is syndemic with other social determinants of health such as access to health services and socioeconomic status.4–6 Legislation that discriminates against lesbian, gay, bisexual, transgender, and queer (LGBTQ) people decreases well-being and increases depression and anxiety.1,7 Antitransgender legislation increased across the United States after 2020,7 and Florida passed some of the most restrictive antitransgender legislation.8 According to the American Civil Liberties Union, Florida state legislators proposed 36 antitransgender bills and passed 7 between 2020 and 2024 (Table 1).9
TABLE 1—
Major Antitransgender Legislation Passed in Florida: 2018–2024
| Introduced | Passed | Bill Name (Nickname) | Policy Area | Antitransgender Content |
| March 2021 | June 2021 | SB 1028: Fairness in Women’s Sports Act | Education, sports | Bars transgender children from school sports |
| January 2022 | March 2022 | HB 1467 | Education | Allows books to be challenged in schools |
| January 2022 | March 2022 | HB 1557: Parental Rights in Education Act (Don’t Say Gay) | Education | Prohibits teachers from discussing gender identity and sexual orientation in grades K–3 |
| February 2023 | May 2023 | HB 1069 (Don’t Say Gay or Trans) | Education | Prohibits teachers from discussing gender identity and sexual orientation in grades K–12 |
| March 2023 | May 2023 | SB 254 (Gender-Affirming Care Ban) | Health care | Bans gender-affirming surgeries and medications for minors, restricts adult care, imposes criminal penalties for doctors |
| March 2023 | May 2023 | SB 1438 (Drag Ban) | Public space | Prohibits minors from attending some performances, targets drag shows |
| March 2023 | May 2023 | HB 1521: Safety in Private Spaces Act (Bathroom Bill) | Public space | Requires bathrooms to align with gender assigned at birth, states that gender is immutable, lists potential criminal penalties |
One prominent Florida bill—HB 1557 (2022), popularized as the “Don’t Say Gay or Trans” bill—prohibited discussions of gender and sexual identity in elementary schools, which later expanded to grades K–12 in 2023. Another bill, SB 254 (2023), banned gender-affirming care for minors, made providing such treatments a first-degree misdemeanor, and allowed state courts to issue warrants to take temporary custody of children receiving gender-affirming care. SB 254 restricted transgender adults’ transition-related care by requiring an in-person physician’s approval rather than approval by nurse practitioners or via telehealth. SB 254 disrupted up to 80% of transition-related health care for adults in Florida.10
Research documents that antitransgender laws that inhibit transgender people’s right to openly exist and receive health care exacerbate the extreme disparities in suicidality and mental health issues between transgender and cisgender individuals.3,11–15 Almost half of transgender people report suicidal ideation and 26% have attempted suicide.16 People who do not receive gender-affirming care have double the risk of experiencing moderate to severe depression and a fourfold likelihood of experiencing anxiety than do those who receive appropriate health care.17 Thus, antitransgender laws endanger the lives and well-being of transgender people and create greater health inequities.7,11,12
Further challenging transgender people’s right to openly exist, HB 1521 (2023, the “Bathroom Bill”) criminalized using a public bathroom designated for a gender that differs from one’s gender assigned at birth. A January 2024 memo from the Florida Department of Highway Safety and Motor Vehicles ended gender marker changes on driver’s licenses in Florida and caused widespread fear by declaring that “misrepresenting one’s gender … on a driver’s license constitutes fraud” and is subject to criminal penalties.18 Transgender individuals who do not have gender-affirming identification report higher levels of psychological distress and suicidal ideation.19–20 Aligned with allostatic load theory, research finds that sweeping discriminatory legislation and accumulated adversities increase chronic stress that leads to “wear and tear” on the body over time with subsequent higher rates of disability and morbidity.21
Research finds that discriminatory legislation increases health disparities across minority groups.5–7 An estimated 111 100 transgender people aged 13 years and older live in Florida.14,22 Transgender people in Florida are overpoliced, are denied basic rights, and face exclusion from health-monitoring systems (i.e., informational and institutional erasure).1,23 The 2018 Human Rights Watch report on transgender women and human rights found a uniquely high-risk environment for transgender women and concluded that in South Florida transgender women face a fragmented landscape for health care that fails to ensure that effective care is available. Research about transgender people greatly benefits from academic–community partnerships.
Our study is a collaboration between university researchers and activists at TransSOCIAL, a grassroots transgender-led community-based organization (CBO) in Florida. We examined the potential impact of antitransgender legislation on the health and well-being of transgender people. We examined the service needs of transgender people in Florida over time and compared results from before and after the increase in antitransgender legislation.
METHODS
We analyzed de-identified administrative intake data from transgender clients in Florida (n = 701; aged ≥ 18 years) who enrolled in services with TransSOCIAL from April 2018 to August 2024. Clients learned about TransSOCIAL’s services through their social networks or at LGBTQ community outreach events in Florida and autonomously sought the CBO’s services. This is a nonprobability sample, and we did not cluster respondents. The intake form stated that anonymized responses may be used for research and that no identifying information would be shared outside TransSOCIAL.
Trained advocacy personnel from TransSOCIAL conducted an intake to connect new clients with services and referrals. This quantitative survey included demographic questions, a checklist of service needs from the organization, and additional assessments on need for legal assistance with name changes and gender markers, housing, and employment. The intake survey has been administered to new clients since 2018. English-speaking clients completed the survey online; Spanish- and Haitian Creole–speaking clients completed the survey over the telephone or in person with advocacy personnel fluent in those languages. Advocacy personnel then shared the de-identified intake data with us in August 2024.
Measures and Variables
Sociodemographics
Age, race, ethnicity, gender, and economic status as indicated by employment status, annual income (income added in 2021; n = 427), and housing status (housing added in 2021; n = 507) were self-reported. We grouped gender into (1) feminine, (2) masculine, or (3) nonbinary gender based on responses to multiple response items and an open-ended item. It is important to note that most clients endorsed and reported multiple gender, racial, and ethnic identities. These responses were reported in multiple groups to represent the array of nonmutually exclusive self-reported identities; therefore, the percentage of responses does not add to 100%. Such operationalization of identities as not mutually exclusive is crucial for studying the health of the transgender population because it accounts for the variability and multiple dimensions of gender, race, and ethnicity.24
Service needs
We categorized TransSOCIAL’s service offerings into 4 domains: legal assistance, health services and referrals, employment services, and basic need services. Clients self-reported each service needed. For legal assistance, clients selected from legal name change, legal gender marker change, obtaining or updating identity documents, and fees required for the identity documents (the fees question was added in 2019; n = 596). Other legal assistance included immigration services and help with filing a discrimination complaint, but because of the small number of these requests, we do not discuss them in this study. For health services and referrals, clients selected from help getting insurance, letter of support for gender-affirming surgery or other gender-affirming care, referral for primary care, mental health provider, hormone replacement therapy or gender-affirming surgery, and sexual health needs (i.e., condoms, lubricant, counseling, sexually transmitted infection [STI] testing, and referral for preexposure prophylaxis [PrEP]). For employment needs, clients selected whether they needed assistance finding employment.
Statistical Analysis
The primary investigator (C. H.) cleaned and analyzed the anonymized data. First, we used R version 4.4 (RStudio, Boston, MA) to calculate proportions for dichotomous and categorical variables and means and SDs for continuous variables. Next, we conducted a change point analysis in a Bayesian regression framework on the daily intake data using R’s mcp package.25 Change point analysis identifies data points that shift trends in a time series and returns reliable estimates for medium (e.g., n = 500) to large samples.26 Change point analysis is used to suggest when a change in a trend may come from a change in policy.25,26 We used change point analysis to examine whether client intake patterns shifted after Florida implemented antitransgender legislation across the state. The mcp package estimates posterior distributions for change points using Markov chain Monte Carlo simulations. Given a number of change points, the mcp package automatically detected where a change point most likely occurred.
RESULTS
From April 18, 2018, to August 1, 2024, 701 clients aged 18 years and older and living in Florida completed TransSOCIAL’s client intake. The study included 49% feminine, 32% masculine, and 25% nonbinary clients. The clients were racially and ethnically diverse, consisting of 54% (382) White, 46% (320) Latinx, and 31% (217) Black/African American clients, among others. The mean age was 28 years (SD = 10.24), with most clients aged between 18 and 30 years. Among the clients, 28% (195) reported being unemployed, and 32% (225) reported being uninsured.
Appendix Tables A and B (available as a supplement to the online version of this article at http://www.ajph.org) summarize clients’ reported sociodemographic characteristics, including gender identity, race, age, annual income, housing status, and financial ability to afford name change fees. A majority (286; 67%) of transgender clients who were asked about income (n = 427) reported making less than $25 000 in the previous year. Of clients who were asked about housing (n = 507), 22% (113) reported not having stable housing, being unhoused, or feeling unsafe in their housing. Additionally, more than half (357) of the respondents could not afford the $400 court fee for a legal name change.
Trends in Transgender Client Intake
Overall, 37 clients sought TransSOCIAL services in 2018, 64 in 2019, 81 in 2020, 129 in 2021, 76 in 2022, 154 in 2023, and 160 in the first 8 months of 2024. Several factors likely affected intake trends, including CBO outreach, CBO staffing, the COVID-19 pandemic, and employment opportunities for transgender people. For example, CBO personnel point to a temporary reduction in paid staff for several months in 2022 and a website outage in October 2022 to explain the decrease in intakes in 2022. Figure 1 illustrates TransSOCIAL’s client daily intake numbers from April 2018 to August 2024.
FIGURE 1—
Transgender Clients Enrolled With TransSOCIAL by (a) Number of Daily New Client Intakes, and (b) Number of Daily New Client Intakes With Bayesian Change Point Detection: Florida, 2018–2024
We suggest that antitransgender policy is a major driver of CBO intake. Although the CBO has recorded an uptick in new clients in most years, there was a substantial increase during the years and months that the Florida legislature pursued antitransgender legislation. Advocacy personnel reported that they saw a spike in requests for help when antitransgender policies were in the news, specifically on social media, and discussed in their informal networks. News coverage of antitransgender policies in Florida are highest during the state legislative session, which runs from January to March in even-numbered years and March to May in odd-numbered years.
Using Bayesian change point analysis, we identified a large shift in the daily intake trend between the end of 2022 and the beginning of 2023. We selected a model with 1 change point and 2 segments with autoregressive errors after comparing R-hat convergence diagnostics across models with 1 to 5 change points and selecting the model with R-hat values closest to 1. The R-hat convergence diagnostic compares the within- and between-chain estimates for parameters from the Markov chain Monte Carlo simulations; an R-hat of 1 means those estimates converge.
Figure 1 plots the daily number of intakes from 2018 to 2024. The peaked lines along the x-axis are the posterior distributions of the estimated change point. The highest peak in the posterior distributions—the area the algorithm identified as the most likely to contain a fundamental shift in the data—occurred in January 2023, when an unprecedented number of antitransgender bills were introduced in Florida and in statehouses around the country.9 After this turning point, the number of daily intakes continued to increase.
Service Need Requests
Table 2 presents the requested service needs. Although clients requested a wide array of service needs, some were more prominent. First, legal services were the most requested, especially legal name changes—TransSOCIAL’s primary service; 92% requested help with legally changing their names, updating their identification documents, or both. Half (353; 50%) of the clients requested health care services or referrals, many for sexual health resources (217; 31%), followed by hormone replacement therapy (74; 11%) and gender-affirming surgeons (63; 9%). About one fifth (130; 19%) requested help with employment, and 22% (113) of clients who were asked about housing reported that they needed stable housing.
TABLE 2—
Requested Services Among Transgender Floridians Enrolled With TransSOCIAL: 2018–2024
| Statistic | No. (%) |
| Need legal assistance | 662 (94) |
| Need assistance in name change process | 646 (92) |
| Need immigration services | 18 (3) |
| Need to file a discrimination claim | 17 (2) |
| Need health care referrals or services | 353 (50) |
| Need condoms, lubricants, or safer sex counseling | 217 (31) |
| Need HRT referral | 74 (11) |
| Need gender-affirming surgeon | 63 (9) |
| Need PrEP | 62 (9) |
| Need STI testing | 58 (8) |
| Need insurance | 59 (8) |
| Need mental health provider | 52 (7) |
| Need primary care doctor | 49 (7) |
| Need letter of support for gender-affirming care | 43 (6) |
| Need stable housinga | 113 (22) |
| Need employment assistance | 130 (19) |
Note. HRT = hormone replacement therapy; PrEP = preexposure prophylaxis; STI = sexually transmitted infection. The study population was n = 701.
For this question, n = 507.
To understand the top 3 service areas that TransSOCIAL offers (i.e., legal assistance, health care services and referrals, and employment assistance), we analyzed the requests by year (we excluded housing, which was not asked about in all years). As shown in Figure 2, the number and percentage of clients requesting these services increased almost annually after the Florida legislature started passing antitransgender laws. In 2024, 155 (97%) incoming clients sought legal aid compared with 33 (89%) in 2018. In the same year, 83 (52%) clients requested health care assistance compared with 10 (27%) in 2018.
FIGURE 2—
TransSOCIAL Clients Requesting Legal, Health Care, and Employment Services by Type of Service (a) Numbers, and (b) Percentages: Florida, 2018–2024
Note. The 3 peaked lines along the x-axis are the posterior distributions of the estimated change point.
Requests for employment assistance displayed a different pattern, which may reflect the COVID-19 pandemic’s impact on employment. The proportion of people requesting employment assistance peaked in 2020 (30% of clients). These requests eased as the job market improved and then increased again in 2023 (30%) before dipping slightly, to 27% in 2024.
Requests for health care services and referrals increased overall and in the proportion of clients requesting them. This growth was driven by a surge in requests for sexual health resources (e.g., condoms, lubricant, STI testing, and PrEP referrals; plotted by type in Appendix Figure A, available as a supplement to the online version of this article at http://www.ajph.org). In 2024, 29% (61) of clients asked for sexual health resources compared with 11% (5) in 2018. Similarly, requests for PrEP and STI testing increased significantly. In 2024, 11% (18) and 12% (19) of clients requested PrEP referrals and STI testing, respectively, compared with 1 client requesting PrEP and STI testing in 2018.
PrEP and STI testing requests doubled between 2022 and 2024. This contrasts with other health care service and referral requests, which either stayed constant or decreased. The increase in requests for sexual health resources is largely driven by an increase in requests from Black clients (Appendix Figure B, available as a supplement to the online version of this article at http://www.ajph.org). Black clients requested sexual health resources at higher rates than did clients with other racial and ethnic identities across all years. Latinx clients requesting sexual health resources contributed to the overall increase in requests in later years.
Black clients requested STI testing and PrEP referrals at higher rates than did other clients. However, the absolute numbers were not as large as those requesting condoms and lubricant. By contrast, White clients requested notably fewer sexual health services than did other clients. For example, 12% (19) of Black clients, 9% (22) of Latinx clients, and 6% (9) of White clients requested PrEP referrals, whereas 12% (19) of Black clients, 10% (24) of Latinx clients, and 3% (5) of White clients requested STI testing. There were no sustained and substantial racial or ethnic differences in other service area requests (Appendix Figures C, D, and E, available as a supplement to the online version of this article at http://www.ajph.org).
DISCUSSION
We found that the number of transgender people requesting services from a CBO shifted dramatically in January 2023 and continued to increase as Florida implemented antitransgender measures. These findings suggest that antitransgender legislation prompts transgender people to seek support, resources, and protection from advocacy groups, which are an important source of resistance to these laws. These patterns emphasize the importance of advocacy groups in providing access to supportive resources and crucial information about legal rights and how to navigate new laws.
Many transgender people in this study reported considerable economic vulnerabilities, in line with other studies on transgender demographics.14–15 Compared with other needs assessment data on the cisgender population, the intake survey data demonstrate that transgender Floridians reported fewer socioeconomic status resources and higher needs than did the cisgender population. For example, in our study, 28% (195) of transgender people reported being unemployed, 32% (225) reported being uninsured, and 22% (113) reported having unstable housing, compared with 3.8%, 12%, and about 1% of cisgender national populations, respectively.15,27 Additionally, requests for sexual health resources (e.g., condoms, STI testing, and PrEP referrals) increased more than other service requests over time and during the antitransgender legislative period.
A high number of individuals sought legal aid across all years, even in years with no antitransgender legislation. This may be unique to our study because of TransSOCIAL’s name change program, which is the largest in Florida. The high prevalence of legal service requests is likely a ceiling effect—requests started high and went higher but cannot exceed 100%—rather than a null effect of antitransgender legislation.
The majority of clients requested help with changing their names and accessing health care. Legal name changes are critical for the social determinants of health among transgender individuals.28–29 Legal name changes provide social and legal affirmation of one’s gender identity and foster a sense of acceptance, which is important in health care settings.20,30 Gender affirmation, which includes legal name changes, is associated with reductions in depression, anxiety, and suicidal ideation.19,31,32 Additionally, legal name changes may increase safety by decreasing discrimination in medical, occupational, and housing settings.28
Limitations
Limitations of this study include the nonprobability sample of transgender Floridians seeking TransSOCIAL services and the observational analysis. The data and our analyses suggest that antitransgender legislation precedes an increase in intakes and that intakes increased as Florida implemented more antitransgender policies. However, observational analyses on a nonprobability sample cannot demonstrate a causal relationship between policy and intakes. Similarly, we expect that other factors also influence intake trends, but we do not have the data to statistically estimate or control for the influence of other factors. These findings cannot be generalized to all transgender people, including transgender people who do not seek TransSOCIAL services in Florida. Additionally, TransSOCIAL is physically located in South Florida, and clients from South Florida are overrepresented in the data set.
TransSOCIAL’s most developed service is assistance with name changes, which means that the need for legal assistance may be overrepresented in this sample.33 Other services (e.g., gender-affirming health care, employment, and housing) may be a top priority for transgender individuals in Florida who seek assistance elsewhere. Despite these limitations, this study provides important insights into the needs of the transgender population in an antitransgender legislative period.
Public Health Implications
There has been an acute and rapid increase in antitransgender legislation at the state and federal levels. As reported by the Trans Legislation Tracker, 2024 was the fifth consecutive record-breaking year for antitransgender legislation: 587 antitransgender bills were introduced across 43 states along with 87 national bills. In the first 100 days of 2025, 854 bills were under consideration across 49 states, including 36 at the national level.34 These bills reinforce harmful medical practices and discriminatory societal attitudes; therefore, they lead to negative health outcomes.2,13,23
Discriminatory policy actions are linked to severe physical and mental health morbidities, as well as increased mortality, in transgender populations.7,11,12 Transgender youths reported an increase in victimization and suicidality during the rise of antitransgender legislation.12,17 To avoid anticipated discrimination, many transgender individuals of all ages avoid or delay seeking necessary health care and treatments, leading to poorer health outcomes, chronic health issues, and downstream consequences from unaddressed health issues.1,2,13,23 Antitransgender legislation will further exacerbate health disparities and barriers to health care, including but not limited to pathologization of gender nonconformity, restricting access to necessary medical care, and increasing stress and stigma, which may lead to an increase in health-harming behaviors used as coping mechanisms.2,7,11–13
Anti-LGBTQ legislation is associated with national economic negative consequences,35 including increasing unemployment, housing instability, and poverty, as well as limiting resources and support, which is associated with poor health among the entire population. Thus, antitransgender legislation is a public health crisis for all, as it endangers the lives and well-being of this population and the communities in which they work, live, and age.
Multifaceted strategies are required to combat inequalities driven by antitransgender legislation. One way is to increase funding for advocacy groups who help transgender clients resist legal discrimination, such as TransSOCIAL. With increased resources, advocacy groups can provide or facilitate access to gender-affirming health care services, mental health support, crisis intervention, and other essential health services. Increased funding to advocacy groups also helps reduce homelessness, housing instability, economic instability, and survival sex work by allowing advocacy groups to offer housing assistance programs, job training programs, and employment placement services. Furthermore, funding can support research initiatives that provide evidence-based data to highlight the negative impacts of antitransgender legislation, which can be used to advocate policy changes.
Addressing these pressing needs and increasing health equity require collaboration between CBOs, scholars, health professionals, legal systems, and policymakers.3,5,24,28,33 This unique data set illustrates the needs of a marginalized population during a period in which legislators specifically targeted transgender people. The size and insights of the data set demonstrate the role of CBOs in collecting vital data on the experiences and needs of marginalized populations, which can directly inform policy, social programs, and health care. This administrative data set is relatively large and covers a long period compared with many other data sets of transgender respondents in public health research. CBOs can reach populations that researchers and health departments struggle to contact. Collaborating with CBOs helps public health officials, health care professionals, and researchers address the social determinants of health and serve transgender communities.
ACKNOWLEDGMENTS
We thank the University of Miami, Laboratory for Integrative Knowledge initiative for funding the preliminary research for this project and the University of Miami, Center for AIDS Research and the National Institutes of Health (NIH) for funding (award 5P30AI073961-17) ongoing data collection and writing for C. Hummel, K. Nowotny, A. Mayfaire, and J. McKenzie. C. Hummel’s work is supported by a Hampton New Faculty grant from the University of British Columbia. T. R. Glynn’s work is supported by the NIH, including the National Institute on Drug Abuse (awards K23DA060719 and L60DA059128).
We gratefully acknowledge the participation of transgender Floridians in the design and implementation of this research during a difficult time for transgender communities across the state. We thank Cameron Riopelle and Avery Everhart for feedback.
Note. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of their employers or the NIH.
CONFLICTS OF INTEREST
A. Mayfaire is a founder and board member of TransSOCIAL. B. Ramos is an employee of TransSOCIAL. J. McKenzie is the executive director of the McKenzie Project, Inc, which works with TransSOCIAL to provide name changes.
HUMAN PARTICIPANT PROTECTION
The University of Miami institutional review board determined the study to be exempt from review. The University of British Columbia Behavioral Research Ethics Board approved the study under minimal risk.
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