Gender-Affirming Care Is On The Line In This Election

RACHEL FELTMAN: This is Science Friday. I’m Rachel Feltman. The election is only a few days away, and we’re continuing our coverage of how science is showing up on the ballot. So far, we’ve discussed the psychology of polling and the science of third trimester abortions.

Now, we’re turning to gender affirming care, which is life-saving treatment for many trans people and could be drastically impacted by the results of this election. This year alone, various states have considered 182 bills aimed at prohibiting gender-affirming care, which can include hormone therapy and surgery. And it’s become a central part of the Trump-Vance campaign. They’ve stated that, if elected, they’ll ask Congress to ban Medicare and Medicaid from covering gender-affirming care.

They’ve also pledged to cut off federal funding to any hospitals and clinics that provide gender-affirming care. And just a quick content note for listeners before we get into this discussion, we will briefly be touching on the topic of suicide. Here to discuss what’s at stake are Dr. Logan Casey, Director of Policy Research for the Movement Advancement Project, also known as MAP. He helps track LGBTQ-related policies across the US. And Kate Steinle, chief clinical officer at Folx Health. Kate, Logan, welcome to Science Friday.

KATE STEINLE: Thanks so much. Excited to be here.

LOGAN CASEY: Thank you. Very much the same.

RACHEL FELTMAN: So Logan, we’ll start with a question for you. The attack on gender-affirming care isn’t new to this election cycle, but it is pretty new. We’ve seen this onslaught of legislation aimed at banning gender-affirming care in the last few years. So my question is, how dramatic of an escalation has this been?

LOGAN CASEY: The escalation in attacks on transgender people and the LGBTQ community more broadly over the past few years has been incredibly dramatic. With respect to gender-affirming care, in particular, as recently as the beginning of 2021, there was not a single state in the country that had a total ban on best practice medical care for transgender youth. And now, today, just a few short years later, 26 states, over half of the country, have some kind of ban or restriction on best practice medical care for trans kids. 23 of those 26 states’ bans were enacted since 2023 alone.

So really, just in a matter of a year and a half or so, almost half of the country enacted one of these bans. And that is a speed of attack that we haven’t seen possibly ever.

KATE STEINLE: I think what the political rhetoric that has been around for the past many years, and what Logan just talked about, how many states are passing legislation is not about the science, right? It’s not about what people actually are doing in clinic or what type of care patients are getting. It’s this moral panic. Of course, people want to protect kids. Of course, they want them to be safe.

Of course, we want to make sure that any type of clinical care that they are getting is evidence-based. It is safe. It is going to have clinical outcomes that are going to make their lives better.

And I think the fact that politicians, and especially during this election campaign, are using this kind of idea that kids are getting surgeries that their parents aren’t consenting to is just– it’s so out of line. It is so untrue. It is just creating this moral panic that confuses people, and it makes people react to that untruth versus the actual studies and what they’re saying.

RACHEL FELTMAN: And speaking of safety, there was a study in Nature earlier this year that looked at how state-level and anti-trans laws actually affect trans and nonbinary teens. And it found that after these state laws were passed, suicide attempts among this group of teenagers increased by up to 72% But moving on from policies affecting kids, lawmakers are also talking about limiting what adults are allowed to do with their own bodies, right?

LOGAN CASEY: Yeah. So, I mentioned how in just a short time we’ve gone from zero to 26 states with bans on best practice care for youth, but what we didn’t talk about yet is the fact that year after year, a growing share of those bills also contain provisions that would impact access to care for adults. And it’s not just limited to the bills themselves, but also other types of government actions. So here in my home state of Missouri, last year, the attorney general issued proposed emergency regulations that would have effectively banned access to medical care for transgender people of all ages, including myself as a transgender person living here in Missouri.

It made national headlines because it was really the first adult-focused ban that, had it gone into effect, would have been a first of its kind across the country. But we’ve also seen similar attacks in Florida attempting to dramatically restrict who can provide health care to transgender adults. And in Ohio, similar proposed administrative regulations that would have also restricted access to care for adults.

And so this is part of a growing trend in the attacks on gender-affirming care. But it’s also not surprising because the folks who are pushing these bans across the country have made it very clear that their goal is not only to prevent access to gender-affirming care for youth. It’s to prevent access to gender-affirming care, period.

RACHEL FELTMAN: And I do want to get deeper into the particulars of what is at stake in this next election. But, Kate, you’re hearing from trans and nonbinary patients every day. How are they feeling right now about this vital health care?

KATE STEINLE: Yeah, we have patients who are crying on the video visits. They are trying to stockpile medications. They are deeply, deeply concerned about the access to health care for this life-saving treatment post-election, especially if the election goes towards the Republican nominee, Trump. And they are concerned about what a federal block could be, or at least limiting coverage for that.

And I think it’s that fear. We already know that there’s such higher rates of depression and anxiety, four times higher rates of depression and anxiety in the trans community compared to the rest of the population. And this is across the many years of having your identity, your access to health care, your ability to just live a healthy, empowered and affirming life be on the TV screens and political ads, on the legislation. It’s just this feeling of being under attack constantly.

And people are anxious. They are depressed. They are feeling socially isolated. They’re getting isolated more and more from some parts of their community who now treat them as an enemy, and that they have to go back into this place where they’re not talking about their identity because they are a target.

RACHEL FELTMAN: And, Logan, Trump is saying that if he’s elected, he’s going to ask Congress to cut gender-affirming care from Medicaid and Medicare. How would that actually play out? And what are your concerns?

LOGAN CASEY: So there are a lot of different paths that scenario could play out through. And so a lot would depend on the specifics of how he would attempt to cut coverage through Medicaid or Medicare. But if it were to happen, it would be absolutely devastating to many transgender people across the country for all the reasons that Kate mentioned earlier about how the world makes it so much harder for transgender people to be trans.

Those same impacts of discrimination and stigma also mean that many transgender people experience discrimination in the workplace, and other things like that lead to much higher rates of economic insecurity and poverty for transgender people, which means that we as a community, on average, are more likely to be low-income and therefore to need access to programs like Medicaid. Now, there’s a lot of politics that would still have to play out because there are existing federal rules about discrimination in health care. And so, of course, any move like that would be litigated and fought by advocates both in the LGBTQ community and more broadly.

But if it were to come to pass, it would be absolutely devastating for many transgender people across the country.

RACHEL FELTMAN: Right. I Believe the figures that one in five trans adults are on Medicaid. So this is really a huge proportion of trans people. And has the Harris-Walz campaign taken a clear position on gender-affirming health care?

LOGAN CASEY: Yeah, I think that there’s some differences of opinion about how clear of a position the Harris-Walz campaign has taken or at least spoken publicly about this. But I think the track record of both Harris and Walz in their respective positions has been pretty clear. In Minnesota, for example. under Governor Walz, Minnesota is one of the many states that, in reaction to all of these attacks on gender-affirming care across the country, their state legislature took the opposite approach and enacted what we’ve been calling a transgender health care shield law that actually works to protect access to gender-affirming care, both for patients and providers. And so I think that sort of track record makes it pretty clear to me what kind of policies we would expect from a Harris-Walz administration.

But I think the reality is that even in a Harris-Walz administration, we’re still in a place where, again, 26 states across the country now have a ban on best practice care for transgender youth. And under a Harris-Walz administration, I think we would reasonably expect that these attacks at the state level to continue, if not escalate, given that there would be a Democratic administration that would be working to protect rights that conservative states or states that don’t share those values about access to medicine would escalate their attacks, including for care for adults.

RACHEL FELTMAN: And, Logan, one of the things that’s most chilling to me about this is that hospitals or clinics that provide gender-affirming care could lose federal funding under Trump’s plan.

LOGAN CASEY: That’s right.

RACHEL FELTMAN: Could you tell us how big of a deal this could potentially be?

LOGAN CASEY: We’ve already talked about implications for Medicaid and Medicare, but what we’ve also seen at the state level efforts to ban gender-affirming care through public funding can sometimes take the form of very broad scope. So not just if you as an individual have Medicaid or Medicare as your insurance, but if your provider is taking any Medicaid or Medicare dollars for the services that they are providing, even if they’re not providing it to you. So if I have private insurance, but the doctor accepts Medicaid, that if they’re getting any Medicaid dollars, they might not be allowed to provide that care even to someone who’s on private insurance. Because they, as the provider, are getting public dollars.

And some of the state bills and bans are written similarly with respect to hospitals and clinics and other institutions that provide care. That if you get those public dollars at all, you would not be allowed to provide gender-affirming care. Depending on how the bill or the potential Trump action would be written. So it could, again, have just dramatically devastating impacts.

KATE STEINLE: That sounds very familiar to the whole playbook with abortion care, right? And also about being able to even refer people who come in to one of those hospitals out somewhere else for an abortion. Do you see that same kind of thing happening then in terms of would it not only be access to the care in that hospital that was federally funded, but also that hospital’s ability to say, we can’t do this, but here’s another place that you can go get it? Would they be able to refer out, or we don’t even know the details yet?

LOGAN CASEY: It would depend on how the Trump action would be written. But it’s absolutely possible that they could write it that way. And many of the state bills do, in fact, not only ban doctors from providing best practice medical care, but some of them also include language about referring. And just as you mentioned, with similarities to attacks on reproductive health care and abortion, many of these bans on gender-affirming care contain even the same language of aiding and abetting and many of the same tactics.

And so I mentioned earlier efforts in Florida to restrict access to care for transgender adults by limiting what kind of doctors or what kind of providers are allowed to provide that care. That’s also a tactic right out of the anti-abortion and anti-reproductive health care playbook, of just trying to chip away at access every way that you can.

KATE STEINLE: And I often think about this from a perspective of a clinician and the head of the clinical team, where these laws are meant to scare clinicians away from providing this care. So it is not just about creating the worry in those patients about getting this access or literally not having the access. The hope on the other side, the reason why these laws are written is that people will be so scared to lose their license that they won’t even do what is actually legal in the state still, because they’re worried and they don’t understand how to read the regulations.

RACHEL FELTMAN: One last question for both of you. Kate, I’ll ask you first. From your perspective, what is a key takeaway for people listening who have maybe never interacted with or considered this kind of care before?

KATE STEINLE: Yeah. I mean, to say it simply, this is evidence-based clinical care. This is safe. This is effective.

This has been proven time after time in multiple national evidence-based journals, as well as practices that this is effective. That this is life-saving, and that people actually engage with both their community, with themselves, with their work, with everything in a different way after they’ve been able to have access to this. It is going to improve mental health. It is going to reduce suicide in this community.

And I think the reality is that this is just like any other clinical care. People who provide this care are not rogue practicers of medicine. They are people who follow the evidence. And I think that’s the thing to keep coming back to. This is clinically safe and effective.

And the scare tactics are just that. The scare tactics are taking untrue stories that people like to create. And completely abolishing the fact that this is clinically evidence-based practice.

RACHEL FELTMAN: Yeah, really well said. Logan, any final thoughts from you?

LOGAN CASEY: Yeah, I would just underscore what Kate said about how much better having access to gender-affirming care can make life for transgender people. As a transgender man myself who’s had access to this care, it has made my whole life possible. And so just from personal experience, that’s absolutely true for me. So thank you for saying that.

There are real human costs to these attacks, both with respect to even when these bills don’t become law. The fact that they have been introduced, that they’re being debated, that our lives and our access to life-saving medicine is up for political debate has a real human toll, not only on transgender people, but also on our families and on our communities more broadly. And when we talk about people moving or considering moving, that also has a toll on the communities that we leave behind when we move somewhere else– the jobs that we are leaving, the communities that we lived in and contributed to, the economies that we were part of. That hurts communities even after we have left. And so there’s real human costs to these bills in all kinds of ways.

And then the other thing is, just as Kate said, at the end of the day, what’s happening here is politicians trying to make medical decisions and take away the ability of people to make those medical decisions for themselves. And while today it’s abortion and reproductive health care and transgender health, tomorrow it could be health for you, if it’s not already.

RACHEL FELTMAN: Absolutely. Thank you both so much for taking the time to talk about this with us.

KATE STEINLE: Yes, of course, I really enjoyed it. Thanks so much.

LOGAN CASEY: Yeah, thank you so much for this opportunity.

RACHEL FELTMAN: Dr. Logan Casey is the director of Policy Research for the Movement Advancement Project. Kate Steinle is the chief clinical officer at Folx Health. Special thanks to Cassius Adair for consulting on this segment.

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