Gender-Affirming Care Ban Considerations

By Dr. Marcus D. Smith, PhD, LCPC + Karli Bigler, M.A., LPC + Ziling Ni (倪子凌 in Chinese) Counselor In Training from Northwestern University

• Plume, 2023: The Attorney General of Missouri sought to place serious restrictions on access to gender affirming healthcare in the state from 4/27/23-2/2024.This emergency rule that is being issued would enforce numerous rules, steps, requirements, and barriers before being able to prescribe gender affirming hormone therapy.  Some major restrictions and concerns shall be discussed here. 

• First, it is required that patients should have undergone at least 15 one-hour-long sessions of therapy over the course of 18 months before seeking and receiving gender affirming care. Not only does this enforce a longer time gap before the care that could be implemented, but it further prevents people who were previously without enough medical resources from getting services. Especially for transgender populations, they often face higher rates of unemployment and poverty, which makes it even more challenging for them to afford ongoing therapy (McKinsey & Company, 2021; National LGBTQ Task Force, 2013). According to a survey cited by McKinsey & Company, nearly 30 percent of transgender people in the United States are not in the workforce, and they are twice as likely to be unemployed compared to the cisgender population (2021). 
• Moreover, the implementation of this policy hinders the opportunity to offer help in emergency contexts to relevant patients, giving rise to higher rates of deteriorating mental health and depression, or even suicidality. Previous studies have suggested a negative association between the age period of gender-affirming care initiation and the mental health status of transgender populations, with later initiation being associated with higher odds of past-year suicidal ideation and past-month severe psychological stress (Turban et al., 2022).  
• Most importantly, implicit discrimination and “conscientious objection” could be invoked by this policy for suggesting that transgender and nonbinary people are experiencing an “illness” that should first be “treated” with therapies. And gender-affirming care shall only be a last resort. It further implies the cultural values that our society is complicit in providing reactionary care versus prevention.  
• Similar implicit discrimination also arises in other major emergency rules that refrain patients from getting gender-affirming therapy. It is required that patients who would like to receive gender-affirming care must be screened for autism and complete an annual gender dysphoria assessment. They also must have gender dysphoria for at least 3 years for moving on to care receiving. With gender dysphoria being identified as a mental disorder in DSM, similar implications apply that gender-affirming care is only for people who have developed a mental illness. In lieu of delaying gender-affirming care, nonbinary and trans communities continue to experience suppression in their identity development.   
• At the same time, to be able to receive treatment, trans patients appear as though they need to prove they aren’t experiencing “social contagion”. This once again denies the authenticity of the transgender and nonbinary populations and their legitimacy of receiving treatment by implying that they are probably just following the herd. This minimization continues to precipitate identify fragmentation (Velez & Beal-Spencer, 2018). According to research with gay black men in the black church in the Chicagoland area, this fragmentation of needs, prevention of access to services in turn impacts individual worth (Smith, 2021).  
• And Even for a part of the patients who managed to get treatment, chronic psychological stress may arise as physicians must track the “adverse effects” of gender-affirming care for at least 15 years. All the restrictions systematically alienated, excluded, and discriminated against transgender and nonbinary populations and their legitimate right for autonomy over medical decision-making. 

 

• Plume, 2023: Florida also issued Bill SB 254, adding new restrictions for individuals seeking gender affirming care, especially limiting youth’s access to care services, despite it being evidence based on organizations including WPATH, American Medical Association, American Academy of Pediatrics, APA, and others. The bill includes that 

• Patients must be 18 years older or have received an informed consent from Florida Board of Medicine and Osteopathic medicine for receiving care. This would, again, pose increased mental health risks, such as depression, anxiety, and suicidal ideation, especially to transgender youth for restricting and delayed access to necessary care (Turban et al., 2022). Thus, it could worsen the significant healthcare disparities that transgender populations are already facing, leading them to the situation of being underserved and at a greater risk for poor mental health outcomes. 

 

• ABC News, 2023:  https://abcnews.go.com/US/map-gender-affirming-care-targeted-us/story?id=97443087  

• States including Alabama, Arkansas, Arizona, Florida, Georgia, Idaho, Iowa, Kentucky, Mississippi, Missouri, Oklahoma South Dakota, Tennessee and Utah and more have passed laws/policies that restrict gender affirming care for both youth and adults.  
• These bills are only some of the 321 anti-LGBTQ bills introduced or debated in 2023 which surpasses a record 315 from 2022. This brings huge concern to the field of counseling and to the gender queer community as these initial steps could imply justification for further restrictions and decline in care. Thus, leaving the community and its providers with hypervigilance and despair.  
• Gender affirming care includes puberty blockers, HRT (Hormone Replacement Therapy), social/legal transitions, surgeries, and more. Clinicians in these states have to grapple with the best care to give their clients as it is known that state laws most times contradict ethical codes of conduct in counseling. In these restrictive states, clinicians are also left with limited protection due to the risk of colleagues and third parties that align with the bands reporting their discovery of affirming care.   

 

• UCLA, 2023:  https://williamsinstitute.law.ucla.edu/publications/bans-trans-youth-health-care/  
• Williams Institute estimates that 156,500 trans youth live in 32 states where access to care has been restricted or is at risk of becoming so. These steps have clear ramifications in client care. Mental health agencies all over would be at risk of causing harm to this entire demographic. The counseling field should question whether it is truly upholding ethical standards in autonomy, beneficence, nonmaleficence, justice & fidelity. Specific ethical decision-making models of counseling encourage clinicians to process where their duty lies in providing care (Sileo & Kopala, 1993). We the bans in affirming care, clinicians have a duty not only to clients and self, but the field of counseling. Continuing to ignore the needs of gender queer communities could cause a decline in individuals seeking therapeutic support and maintaining a culture of clinicians complicit in being selective when advocacy and human rights should be acknowledged and honored.  

 
Recommendations: 
 

• Training & Supervision:  

Educate yourself and stay up to date on gender affirming care bans in your state. These bans           impact gender expansive individuals, the healthcare community, and the Queer community. In supervision and personal therapy for practicing, clinicians shall be mindful to explore potential      implicit bias with queer communities. Implicit bias comes from three preferences (neutral, positive, or negative) (Tyner, 2019). Usually, implicit bias doesn’t favor our explicit or declared values (Kirwan Institute, 2018). Even if our bias towards queer communities is neutral that can lead to distance or disinterest. This disinterest then can lead to neglect which leads to potential harm concerning clinical environments. The parallel is that clinicians may not engage in advocacy for individual needs and engage in maltreatment with the assumptions this population presents with severe mental illness when in actuality these individuals are engaging in flexicurity (Berntson, 2008), which is a concept in developmental psychology that explains how minority clients aren’t failing in their development but in actuality they are successfully navigating systems that don’t have their best interest.  
 

• Advocacy:  

 
Community & Federal 
Clinicians may want to partner with nonprofit organizations and explore community grants to enable free access to community care for Queer folk.  Communities could also create local LGBTQ+ support groups and other supporting organizations that provide information, resources, and emotional connections and support to Queer individuals and their families. 
 
Academia  
Support research efforts that demonstrate the efficacy and safety of gender-affirming      care. This data can be used to inform federal policies and challenge discriminatory practices. 
 
Clinician 
Clinicians should stay updated on the latest news and regulations of gender affirming care bans and consciously checking in with their clients about their current concerns or mental responses on related issues.  
 
Clinicians should actively collaborate with other professionals or providers who are    supporting gender affirming care, which involves referring clients to supportive medical            providers, legal experts, or community organizations, and have a resource list available for clients. Along the lines of additional professional development, clinicians should consider membership with organizations such as SAIGE (Society for Sexual, Affectional, Intersex, and Gender Expansive Identities) and WPATH (World Professional Association of Transgender Health) to increase knowledge and skills concerning standards of care.  
 
Clinicians may want to consider using integrative models to support clients externalize experiences of oppression as they are not innate. Also, these models would encourage clinicians to process      with queer clients how they can cope with discrimination outside of an individualistic lens. For example, The Multiple Minority Stress Model (Rich et al., 2020) explores how prejudice and inequity of a queer persons’ identity impact how they cope with psychological, biological and social challenges.    
 
Clinicians should create and provide an open and safe counseling environment for clients to discuss topics or concerns related to gender-affirming care. Besides ensuring the confidential nature of the conversations and the limits of confidentiality, simple cues of always asking and using a client’s pronouns and self-identified names would contribute to a sense of validation and safety for transgender and gender non-conforming clients. Also, clinicians could display visible signs of inclusivity in the workspace, including transgender pride flags or artworks or books related to authenticity. 
 
Trans & Binary Persons
 
Prioritize personal mental health by actively seeking support from therapists, clinicians, or community organizations specializing in gender identity issues. Stay informed about relevant mental and legal resources in local areas or those in more supportive states if possible. And educate oneself and practice self-care routines that promote emotional well-being. 
 
Find and join inside and outside supportive networks and groups, including friends, families, forums, online communities for Queer populations, and local LGBTQ+ groups, to strengthen ties, share personal experiences, and exchange resources. 
 
Engage in advocacy activities of awareness campaigns and educational events and share personal stories and experiences if comfortable to promote humanizing the issue and bringing it into public awareness. Reach out to community leaders, local representatives, or lawmakers to express concerns about the bans and the importance of gender-affirming care. 
 
Resources:  

• Human Rights Campaign: 

• https://www.hrc.org/resources/attacks-on-gender-affirming-care-by-state-map?utm_medium=ads&utm_source=GoogleSearch&utm_content=GACMap-General&utm_campaign=GoogleGrant&utm_source=GS&utm_medium=AD&utm_campaign=BPI-HRC-Grant&utm_content=657195962805&utm_term=anti%20trans%20bills&gclid=CjwKCAjwjYKjBhB5EiwAiFdSfqSLnyKTgDZ9j480F5_GuqLYvMzGi3TrKORORZ6H-UhZo663lYqoyRoCzcYQAvD_BwE  

• UCLA Williams Institute: 

• https://williamsinstitute.law.ucla.edu/publications/bans-trans-youth-health-care/  

• SAIGE: 

• https://saigecounseling.org/ 

• WPATH  

• https://www.wpath.org/soc8  

References: 
 

• Kirwan Institute. (2018). Implicit Bias Module Series. Kirwan Institute for the study of race and ethnicity. https://kirwaninstitute.osu.edu/implicit-bias-training 
• Sileo, F. J., & Kopala, M. (1993). An A-B-C-D-E worksheet for promoting beneficence when considering ethical issues. Counseling and Values, 37(2), 89–95. doi:10.1002/j.2161- 007X.1993.tb00800.x  
• Smith, M. D. (2021). The Lived Experience of Gay Black Men in the Black Church Through the Lens of Intra-Racism and Toxic Masculinty (Order No. 28313965). Available from ProQuest Dissertations & Theses Global. (2494892169). http://turing.library.northwestern.edu/login?url=https://www.proquest.com/dissertations-theses/lived-experience-gay-black-men-church-through/docview/2494892169/se-2  
• Tyner, A.R. (2019). Unconscious bias, implicit bias, and microaggressions: What can we do about them?  American Bar Association. https://www.americanbar.org/groups/gpsolo/publications/gp_solo/2019/july-august/unconscious-bias-implicit-bias-microaggressions-what-can-we-do-about-them/ 
• Velez, G., Beal-Spencer, M. (2018) Phenomenology and Intersectionality: Using PVEST as a Frame for Adolescent Identity Formation Amid Intersecting Ecological Systems of Inequality   
• https://www.nytimes.com/2023/04/15/upshot/bans-transgender-teenagers.html  
• https://abcnews.go.com/US/map-gender-affirming-care-targeted-us/story?id=97443087 
• https://getplume.co/blog/urgent-support-for-our-community-in-florida-sb254/ 
• https://getplume.co/blog/no-cost-emergency-support-for-missouri/  

• National LGBTQ Task Force. (2013, September 6). Transgender Workers at Greater Risk for Unemployment and Poverty. Retrieved November 1, 2023, from https://www.thetaskforce.org/transgender-workers-at-greater-risk-for-unemployment-and-poverty/  
• McKinsey & Company. (2021, December 15). Transgender people twice as likely to be unemployed. Retrieved November 1, 2023, from https://www.mckinsey.com/  
• Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLos one, 17(1), e0261039.