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Markkula Center for Applied Ethics

Transitions in Turmoil: The Impact of Gender-Affirming Care Restrictions on Health Care Providers

Rainbow pride flag and stethoscope. Transgender and LGBTQ+ healthcare and mental health concept. Photo By JJ Gouin_Adobe Stock.

Rainbow pride flag and stethoscope. Transgender and LGBTQ+ healthcare and mental health concept. Photo By JJ Gouin_Adobe Stock.

Kathryn Rickwa ’24

Rainbow pride flag and stethoscope. Photo By JJ Gouin/Adobe Stock.

Kathryn Rickwa is a double major in public health science and biology and has a minor in Spanish. She is also a 2023-24 health care ethics intern with the Markkula Center for Applied Ethics at Santa Clara University. Views are her own.

Legally preventing providers from practicing and providing gender-affirming care to their patients is unethical. These restrictions have serious implications for health care providers who wish for nothing more than to fulfill their vocations to the best of their abilities.

 On a global scale, transgender people have consistently experienced scrutiny, exploitation of their identities for the sake of politics, and systemic barriers that prevent them from surviving and thriving in peace and on their own terms. One critical resource that has been particularly limited and attacked in recent years is access to gender-affirming health care, particularly for transgender and gender non-conforming youth. Since 2021, 24 states have passed legislation limiting youth and adolescent access to gender-affirming care, directly impacting 38% of transgender youth in the U.S.—equivalent to over 144,000 individuals. Restrictions on gender-affirming care directly affect transgender and gender non-conforming people’s ability to access the resources necessary to survive and thrive, but they are not the only ones negatively impacted by these harmful policies. 

What is gender-affirming care? What is the role of physicians in supporting transgender and gender non-conforming patients?

 Gender-affirming care refers to a range of social, psychological, behavioral, and medical interventions that support and affirm a person’s gender identity, particularly when it conflicts with that assigned at birth. Gender-affirming care can include counseling, hair removal, speech therapy, puberty blockers, hormone therapy, and surgery. Usage of gender-affirming care is a deeply individual and personal experience, and utilization varies significantly depending on a patient’s age, personal preferences, health care access, and other environmental factors that influence medical decision-making. Transgender people all have their own journeys with gender-affirming care, and health care providers are a critical resource in supporting transgender people through this life-changing and life-saving process. 

 Within health care and medical professional communities, gender-affirming care is universally considered to be life-saving and necessary for transgender and gender non-conforming patients. Leading medical authorities such as the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Association, American Psychiatric Association, and the American Public Health Association all recognize gender-affirming care as evidence-based, medically necessary treatment for transgender and gender non-conforming patients. As advocates and caretakers, physicians are morally obligated to stand in solidarity with their patients and actively engage in achieving social justice, especially those who are already marginalized. Unfortunately, as in the case of gender-affirming health care, restrictive state legislation actively prevents physicians from fulfilling their vocation justly and equitably, and physicians themselves likewise face harmful consequences.

What is the current status of restricting physicians from providing gender-affirming care?

 States restricting access to gender-affirming care often do so by directly penalizing providers who administer gender-affirming care, most prominently for trans adolescents. 22 states currently impose professional or legal penalties on health care practitioners who provide transgender youth with gender-affirming care. Depending on the state and legislative writing, penalties range from disciplinary action from state licensing boards, revocation of one’s medical license, civil suits, and even felony charges. For example, in Alabama it is now a felony to prescribe puberty blockers and hormone therapy to youth and adolescents, with a potential prison sentence attached. In Utah, it is illegal to “aid and abet” access to gender-affirming care, such as through referring a patient to another provider. While there is substantial variation across state lines regarding what forms of treatment providers can legally provide, fear of liability has resulted in some providers stopping gender-affirming care altogether, even where laws are vague and potentially navigable. This criminalization of providing gender-affirming health care has extremely concerning ethical implications.

Why is legal prevention unethical?

 Due to the rapid changes in policy and significant variations across state lines, physicians and health care providers are encountering major challenges preventing them from fulfilling their vocations. Legal restrictions on the types of care they can and cannot provide—typically created by government representatives lacking experience and expertise in transgender medicine and health care—violate providers’ professional obligations and oaths of upholding patient beneficence, nonmaleficence, justice, and autonomy. Because providers are legally barred from providing best-practice medicine, they are inherently compromising their commitment to doing no harm, acting in their patient’s best interests, respecting patient decision-making and desire for gender-affirming care, and upholding justice and equity for transgender people. Such legislation also directly infringes on confidentiality, which is critical in establishing trust and dialogue between a patient and their provider. Physicians themselves are also harmed by restrictive laws on gender-affirming care. 

 Health care providers of all specialties and subjects dedicate so much of their lives to medically and emotionally support their patients, develop strong relationships with their patients and colleagues, and actively expand their knowledge and expertise to be inclusive and well-equipped in treating patients from all backgrounds and needs. While there are physicians who treat exclusively transgender patients, family medicine practitioners and specialists in all fields regularly encounter transgender patients seeking health care for gender affirmation and other medical concerns. Consequently, any physician treating a transgender patient could have their relationship with that patient compromised and damaged by recent legislation; lack of trust, comfort, and security in accessing care are extremely detrimental to patient-provider relationships.

 A physician’s quality of life also can be significantly impacted by the passage of this legislation. Because legislation has been so recent and constantly changing, little to no research has been conducted on the health outcomes for physicians as a consequence of bans on gender-affirming care. Yet stress and mental health repercussions are being observed among providers who treat transgender patients and reside in states where restrictions are being implemented. Providers have expressed concern about dwindling career longevity, threats to personal safety, potential for legal action against them, and institutional shifts that will limit their ability to adequately care for their patients. Like many families of transgender youth, physicians are also faced with potentially moving out of state in order to continue to provide best-practices medicine, requiring them to uproot their lives and leave behind family, friends, a region, career roots, and more.

 While challenges of these bills through the legal system are in progress, rulings in favor of physicians practicing gender-affirming care have yet to pass. Health care providers across the country are now face-to-face with impossible situations and heartbreaking ethical dilemmas. Do you risk losing your practice or medical license by providing life-saving care to your transgender patient? Do you refer your patient out-of-state or to another care provider, an action which could also have harmful repercussions on you, another provider, or your patient? You can leave the state in order to practice care without restrictions, but is it worth it to uproot your life and say goodbye to your patients who trust you, depend on your expertise, and value the relationship you’ve built together? Physicians and health care workers seek to provide the best treatments and care options available to their patients, yet state-imposed ramifications actively prevent them from fulfilling their role as care providers.

Where do we go from here?

 Gender-affirming care is universally agreed upon by national and international medical organizations as medically necessary and lifesaving for transgender and gender non-conforming patients. Physicians and health care workers seek to provide the best treatments and care options available to their patients, yet state-imposed ramifications actively prevent them from fulfilling their role as care providers. In order for physicians and health care providers to equitably and ethically practice their professions, they must have support in being able to provide gender-affirming care without fear of professional repercussions, legal consequences, mental health challenges, and other ramifications for defying unjust laws. Legally preventing providers from practicing and providing gender-affirming care to their patients is unethical for both patients and health care providers, and, if we hope for justice and equity to prevail, overhaul of bans on gender-affirming care is an immediate necessity.


May 29, 2024

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