Proper Care of Transgender and Gender Diverse Persons in the Setting of Proposed Discrimination

A Policy Perspective

Abby Walch; Caroline Davidge-Pitts; Joshua D. Safer; Ximena Lopez; Vin Tangpricha; Sean J. Iwamoto


J Clin Endocrinol Metab. 2021;106(2):305-308. 

Transgender and gender diverse (TGD) individuals face significant barriers to accessing health care. Recent introductions of regulatory policies at state and federal levels raise concerns over the politicization of gender-affirming health care, the risks of further restricting access to quality care, and the potential criminalization of healthcare professionals who care for TGD patients. The Endocrine Society and the Pediatric Endocrine Society have published several news articles and comments in the last couple of years supporting safe and effective gender-affirming interventions as outlined in the 2017 Endocrine Society's Clinical Practice Guidelines. The Endocrine Society Position Statement on Transgender Health also acknowledges the rapid expansion in understanding the biological underpinning of gender identity and the need for increased funding to help close gaps in knowledge about the optimal care of TGD individuals. This Policy Perspective affirms these principles in the context of pending and future legislation attempting to discriminate against TGD patients while also stressing the need for science and health care experts to inform health policies.

Over this past year, there have been numerous state legislative and federal regulatory policies introduced regarding the care of transgender and gender diverse (TGD) individuals in the United States. These proposed policies appear to have been developed without the involvement of experienced medical providers and without the consideration of evidence-based standard of care clinical practice guidelines on the care for TGD individuals, including those published by the Endocrine Society.[1,2] Not only do these policies ignore the science, but if enacted, they would restrict access to health care for TGD people, and in some cases, would criminalize their medical providers.

TGD individuals have a gender identity that is different from the sex recorded at birth. In 2016, an estimated 0.6% (or 1.4 million) adults reported that they were transgender or gender diverse in the United States..[3] According to a 2017 survey of US high school students, almost 2% reported that they were transgender.[4] TGD individuals comprise a vulnerable group in our society that already faces significant barriers in accessing equitable health care despite the current protections that exist surrounding a person's gender identity.[5–8]

At the federal level, the US Department of Health and Human Services (HHS) announced on June 12, 2020, that it had finalized revisions to Section 1557 of the Affordable Care Act (ACA), which would involve a rollback of health care nondiscrimination rules on the basis of sex, gender identity, and sex stereotyping.[8] These revisions would eliminate protections for TGD individuals who experience discrimination in health care settings, restricting access to gender-affirming care and to general medical care. The Endocrine Society opposed the proposed rule and submitted comments to the US Department of HHS urging it to withdraw it, stressing that removing these nondiscrimination protections would have made it easier for providers to deny care to TGD persons as well as discourage patients from seeking routine and gender-affirming care or reporting discrimination.[9] On August 17, 2020, the day before the revisions to Section 1557 of the ACA were to take effect, a federal judge temporarily blocked them pending future court proceedings. The decision was made following the US Supreme Court ruling on June 15, 2020, which found that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals cannot be discriminated against in the workplace on the basis of sex.[10,11] The ruling was made after consideration of 3 cases, including the case of Harris v. Equal Employment Opportunity Commission in which the Endocrine Society provided scientific background and context regarding transgender health with a "friend of the court" brief.[12] In retrospect, it has been noted that the US Department of HHS announced its planned revisions to Section 1557 of the ACA just 3 days before the expected US Supreme Court ruling, and this timing raised concerns that deliberate attempts were made to remove the protections for LGBTQ individuals in advance of the anticipated ruling.[11]

At the state level, proposed legislation with implications for discrimination of TGD individuals in health care settings first appeared and proliferated in the wake of a heavily publicized custody case of a transgender child in Texas in October 2019. Misinformation regarding the care of TGD youth spread, which instigated proposed legislation to prohibit medical interventions in these patients. This prompted the Endocrine Society and the Pediatric Endocrine Society to release statements affirming our support of the Endocrine Society's Clinical Practice Guidelines on the Endocrine Treatment for Gender-Dysphoric/Gender-Incongruent Persons.[1,13] Unfortunately, since that time, more than 2 dozen bills have been introduced in 16 US states (Alabama, Colorado, Florida, Idaho, Illinois, Iowa, Kentucky, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, and West Virginia), many with the same or very similar titles, wording, and objectives.[14] Although most of these bills have failed to advance in state legislatures, a few remain under consideration. State legislators promoting these bills have spread erroneous and misleading information regarding TGD care of minors. For example, the following was presented as 1 of the 10 ballots of the 2020 Texas Republican Party primary election: "Texas should ban chemical castration, puberty blockers, cross-sex hormones and genital mutilation surgery on all minor children for transition purposes, given that Texas children as young as three (3) are being transitioned from their biological sex to the opposite sex." Even though "chemical castration" and "genital mutilation" are not part of gender-affirming care for minors, such wording serves to alarm the general public, and 94.57% of the electors supported the measure.[15] This type of misinformation has led to an increase in threats to clinics and providers of TGD minors.

These state bills aim to make it unlawful to provide medical care to TGD minors, including the provision of gonadotropin-releasing hormone agonist therapy for pubertal suppression and gender-affirming hormonal therapy. Pubertal suppression, which is fully reversible, is offered to adolescents who meet diagnostic and treatment criteria, and are requesting care, for gender dysphoria/gender incongruence after they exhibit physical changes of puberty (Tanner stages G2/B2).[1] This intervention allows for expansion of the diagnostic phase and more time for adolescents to explore options and live in the experienced gender before making a decision to proceed with gender-affirming hormone therapy.[1] Gender-affirming hormone therapy is partially irreversible and is an option for adolescents who request treatment after a multidisciplinary team of medical and mental health professionals confirms the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent.[1] Gender-affirming hormone therapy allows for the induction of puberty and phenotypic changes that hopefully align more with one's gender identity.[1]

Eliminating these aspects of health care will detrimentally affect TGD patients who face a disproportionately high rate of suicide, yet gender-affirming care is known to significantly improve mental health outcomes.[1,2,4,16–21] Furthermore, the bills would criminalize health care professionals who provide this care with felony charges, revocation of their professional medical licenses, monetary fines, and imprisonment. If passed, the legislation would greatly affect members of the Endocrine Society and the Pediatric Endocrine Society who provide gender-affirming care, particularly those who provide care to minors following the Endocrine Society's Clinical Practice Guidelines for Gender-Dysphoric/Gender-Incongruent Persons and the World Professional Association for Transgender Health's Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People.[1,2] For these reasons, we emphasize the need to involve expert medical professionals or consideration of standard of care evidence-based clinical practice guidelines when developing legislation impacting the health care and access of TGD individuals. The Endocrine Society and the Pediatric Endocrine Society firmly believe that health care treatment should be evidence-based and doctor-patient determined without politicization that is not based on science.

The Endocrine Society and Pediatric Endocrine Society remain hopeful that pending and future legislation attempting to discriminate against TGD patients will not be enacted. Yet, we also recognize the long road ahead in truly attaining equitable health care for all people. We affirm the Endocrine Society Position Statement on Transgender Health, which includes the following: (1) there is a durable biological underpinning to gender identity that should be considered in policy determinations; (2) medical intervention for transgender individuals (including both hormone therapy and medically indicated surgery) is effective, relatively safe (when appropriately monitored), and has been established as the standard of care, and federal and private insurers should cover such interventions as prescribed by a physician as well as the appropriate medical screenings that are recommended for all body tissues that a person may have; and (3) increased funding for national research programs is needed to close the gaps in knowledge regarding transgender medical care and should be made a priority.[22]

In summary, our concern regarding the attempted politicization of the gender-affirming care of TGD individuals persists. At the same time, the Endocrine Society and the Pediatric Endocrine Society remain dedicated to providing necessary gender-affirming medical care to TGD individuals, to advocating for increased funding for research to close the gaps in knowledge regarding the medical care of TGD individuals, and to sharing important knowledge learned to inform policy. We remain steadfast in our belief that patient health management decisions should be evidence-based and doctor-patient determined, and health policy should be based in science with health care experts at the table as contributors.