The real-life cost of America’s war on trans healthcare

While there is a ‘controversy’ over gender-affirming healthcare in the US, in one sense it’s not controversial at all. Every credible medical organisation, including the American Medical Association and the American Academy of Pediatrics, recognises it as a necessary and life-saving form of treatment. As far as expert consensus goes, it’s a settled question, and has been so for a long time. But attacks on trans healthcare are intensifying at a dizzying rate, with a number of states seemingly in competition to see who can pass the cruelest and most extreme laws.

According to data released last week by Human Rights Campaign, America’s leading LGBTQ+ civil rights organisation, half of trans young people now face losing access to gender-affirming care, such as puberty blockers and hormone therapy. “What we’re seeing is legislation that's derived from ideology, rather than medical best practice,” Laurel Powell, deputy director of communications at HRC, tells Dazed. “Trans youth already face alarming rates of discrimination, harassment and violence, and it is unconscionable to see many lawmakers playing politics with their lives.”

Of the anti-trans bills passed in recent months, some allow young people to access gender-affirming care in cases of “extreme dysphoria”, while others leave an exemption for those who are already receiving treatment. But a number of states are going a step further: following in the footsteps of South Dakota and Tennessee, Iowa has banned doctors from providing gender-affirming care for anyone under the age of 18, including those who are already receiving treatment, who will be allowed a grace period of six months before their care is terminated. In response to these laws, families with trans kids are already uprooting their lives and moving to different states, which raises the possibility of a wider trans refugee exodus within the US.

There has been little research done on the effects of forced detransition, which has only become a legislative tactic within recent years. But we do know that gender-affirming care is associated with significant mental health benefits, and that the inverse is also true. According to a recent study by The Trevor Project, young trans people receiving hormone therapy reported significantly lower levels of depression and suicidal ideation compared to those who wanted it but were denied access. The psychological impact of forced medical detransition is likely to be extremely traumatising: as Democratic senator Zach Wahls argued earlier this month, “Iowa children will die if this becomes law.” These latest bans will affect teenagers who have lived almost their entire lives in line with their gender identity, and will now have to undergo unwanted physical changes, at odds with who they are and how the world sees them. “These proposed healthcare bans reflect extreme government overreach and an invasion of privacy,” Alex Schmider, director of Transgender Representation at GLAAD, tells Dazed. “They won’t stop trans people from existing, but they will undoubtedly make it more difficult for us to live healthy and happy lives.”

Powell also stresses that the denial of healthcare is only one part of a “disturbingly broad” campaign. Alongside bans on medical treatment, a number of states – including Montana and Kentucky – are legislating social transition out of existence. These bills involve banning trans kids from changing their names or gender markers; granting students the legal right to misgender and deadname their classmates; forcing schools to report social transition to parents, even where there is a risk of abuse, and prohibiting mental health counsellors from “affirming” trans identities in any way. When it comes to mental health, social transitioning is every bit as crucial as medical care: one study showed a 65 per cent reduction in suicide risk in situations where trans kids have their correct names and pronouns used. Making social detransition impossible, or so stressful and unpleasant it may as well be, serves the same goal as healthcare bans: forcing trans young people back into the closet.

It would be bad enough if these laws were only affecting young people, but the Republicans are beginning to expand their scope. Oklahoma recently proposed a bill that would prohibit insurers from covering trans healthcare, at any age, and ban it outright for anyone below the age of 26. Similarly, Florida has made it illegal for Medicaid (a state-run insurance system for people with limited income) to provide gender-affirming care for trans adults. The state is currently proposing an even more extreme law that would extend this ban to include private insurers, which, if passed, would force trans Floridians either to pay for their own treatment, out-of-pocket, or detransition. The costs involved can be so exorbitantly high (running up to tens of thousands of dollars) that, for most people, this won’t be a real choice.

While the anti-trans panic has so far mostly focused on children, forced detransition for every trans person has always been the direction of travel. The latest wave of anti-trans legislation is not a response to an upswell of grassroots sentiment in the affected states (however transphobic these may be). These laws have passed thanks to the result of tireless and well-funded lobbying by a coalition of conservative organisations, who, for the most part, aren’t being coy about what they want. In a recent New York Times interview, the president of one of these groups stated outright that their goal is to ban transition care altogether, and that focusing on children was only a matter of “going where the consensus is”. People have described this kind of rhetoric as ‘genocidal’ with good reason: making it impossible to transition would effectively eliminate the trans community as a class of people.

This is all extremely grim, but the fight isn’t over yet. Several anti-trans bills have already been defeated or vetoed, and where they have passed, there have been some successful legal challenges: a recent anti-trans bill in Arkansas, for example, was temporarily blocked by a district judge. Last month, Nebraska senators Machaela Cavanaugh and Megan Hunt (who herself has a trans son) successfully stalled the passage of a law that would require medical detransition for trans youths; at one point, in an effort to disrupt the session, Cavanaugh explained the plot of Madagascar in excruciating detail. “What I know, in my heart of hearts, is that you can’t hate what you know,” says Powell. “As more parents of trans youth and more trans youth themselves speak out, and as people see the harm that these attacks are causing to families, we will see more and more resistance.”

By leaning so heavily into the anti-trans panic, Republicans are in danger of overplaying their hand: a survey published yesterday found that a 54 per cent majority of Americans oppose criminalising gender-affirming care for minors, including 56 per cent of swing voters. Even a majority of Republicans think the number of anti-trans bills is an ‘excessive’ form of political theatre. “I don’t believe it’s a winning strategy for them,” says Powell. “This is not something that the majority of the American people agree with.” We can already see a grassroots movement emerging in opposition: one piece of anti-trans legislation in Ohio was recently defeated by the organising efforts of young trans people, while states like Kentucky have seen energetic protests from the trans community, their friends, families and allies. In places affected by the healthcare bans, activists are figuring out how to mitigate the effects, whether through fundraising or organising shuttle buses so that trans kids can access out-of-state care. After decades of experience, the trans community is well-practiced at looking after itself in the face of hostility. But these attacks are getting worse, the stakes are becoming higher, and it’s clear that the rest of American society needs to start mobilising at a much greater scale.