- May 17, 2024
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Until recently, Brendon’s life mostly revolved around the typical college student stuff.
He hangs out with his friends and partner, studies photography and cares for his dog Magic, parakeet Bluey and bearded dragon Mushu.
But now Brendon, 19, is facing a less typical worry.
New state legislation limiting gender-affirming care for adults and banning it for minors has made it harder for Brendon — a Palm Coast transgender man taking prescribed testosterone — to get his medication.
Some Floridians are leaving the state because of the restrictions. Palm Coast resident Cris, 45, has an 11-year-old transgender son, Finn. Cris said she’s already planning to move out of state with Finn.
She wants him to be able to get gender-affirming care if he needs it, and she worries that the state could take him away: One provision of a new state law labels gender transition care for minors as “serious physical harm” warranting court intervention.
“If we move [north], the state of Florida can’t easily force Finn to come back,” Cris said.
Flagler Pride co-founder Erica Rivera said she knows multiple trans people who want to leave the state, and one Flagler resident who already has.
“It hurts my soul to see them go through that,” she said.
On social media, trans Floridians discuss possible future restrictions and how to fight or circumvent them. Some debate the safest states to move to, referencing trans writer Erin Reed’s Anti-Trans Legislative Risk Map, which color-codes states based on whether they have passed or are considering restrictive or protective laws. One state — Florida — is dark red, labeled “Do Not Travel” in the map key.
I’ve lived here my entire life, and now I just don’t feel safe here. Florida doesn’t feel like a home anymore.”
—BRENDON, transgender Floridian
Leaving Florida is a backup plan for Brendon and his partner.
Brendon would like to stay. His whole world is in the Sunshine State: his family, his school and his dream job at Disney.
But now he’s constantly worrying about his and his friends’ safety. “Things are getting really bad,” Brendon said.
His partner’s lease is ending soon. Then, they might leave.
“I’ve lived here my entire life, and now I just don’t feel safe here,” he said. “Florida doesn’t feel like a home anymore.”
Senate Bill 254, the Florida law that’s worrying Brendon and Cris, is part of a wave of legislation placing new restrictions on trans people.
Twenty states have enacted laws banning or limiting gender-affirming care, mostly for minors, in recent years. Most passed during the 2023 legislative session, when Republican legislators across the U.S. proposed more than 450 bills affecting the LGBT community.
In Florida, Gov. Ron DeSantis signed a series of LGBT-related bills into law. One bars transgender people from using the restrooms matching their gender identity in government buildings, one bans the use of trans people’s pronouns in schools, and another, recently found unconstitutional by a federal judge, bans drag performances in places where children could view them.
SB 254, “Treatments for Sex Reassignment,” took effect immediately after DeSantis signed it on May 17.
It prohibits gender-affirming treatments for minors and limits access for adults.
Health care practitioners who provide puberty-blocking medication, cross-sex hormones or gender-affirming surgery to minors face third-degree felony charges and suspension of their medical license. An exception allows minors who were already taking gender-affirming medication as of May 17 to continue.
The law also bars health care providers other than Florida-licensed physicians from prescribing cross-sex hormone therapy to adults or children, mandates that doctors see trans patients in person and not through telehealth, and requires trans patients to sign a new consent form approved by the Board of Medicine and Board of Osteopathic Medicine.
Another section of the law allows courts to remove a child from their family if the child “has been subjected to or is threatened with being subjected to sex-reassignment prescriptions or procedures.”
The law also bans the use of state funds for gender-affirming care for minors and adults and bars government insurance plans in Florida from expending state money to cover it.
Republican legislators pushing new restrictions on trans health care say they are trying to save young people from irreversibly changing their bodies before they are mature enough to know what’s right for them.
Rep. Randy Fine, R-Palm Bay, has been a vocal opponent of gender-affirming care.
“The butchering of children will be illegal in Florida, Florida citizens will not be obligated to pay for the sexual mutilation of adults, and those tricked into this evil will have 30 years to sue those who misled them,” Fine wrote on Twitter March 3 about a related bill he’d introduced. “That’s HB 1421 and I am proud to file it.”
No major U.S. medical associations have supported legislative restrictions on gender transition care.
Instead, many, including the American Medical Association, the American Academy of Pediatrics and the American Psychiatric Association, have issued statements opposing restrictive legislation.
Licensed clinical social worker Cynthia Fischer, of Emergence Counseling in Daytona Beach, has been working primarily with transgender people for 11 years.
She said people seeking gender-affirming care already go through a thorough evaluation process before any permanent interventions.
“It is intended to reduce regret,” she said.
Fischer said detransition — in which someone who has started a gender transition reverses it — is uncommon.
When it does happen, people who have detransitioned can be left with distress that parallels the dysphoria that trans people transition to mitigate.
A 2021 study by psychiatrist Dr. Jack Turban, then of Stanford University, and colleagues at Harvard Medical School and Boston University notes that there is “a paucity of data” on detransitioning. It reports a detransition rate of 13% and states that of those who detransitioned, 83% cited external factors like family rejection or social stigma as reasons for doing so.
A 2022 study from the Netherlands followed 720 youths who began puberty blockers. It found that 98% continued with their transition, progressing to cross-sex hormones. A 2021 analysis of 27 studies and 7,928 transgender surgery patients found that approximately 1% regretted their surgeries.
Some experts have urged caution, pointing out that the number of young people identifying as transgender and seeking gender-affirming care is rising, and it’s not clear if the low regret rates seen in previous generations of trans patients will hold for youths transitioning today.
A Reuters analysis found that almost three times as many youths received gender dysphoria diagnoses in 2021 as in 2017.
Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood."
— Standards of Care Version 8, World Professional Association for Transgender Health
The World Professional Association for Transgender Health’s most recent Standards of Care, released in 2022, acknowledges the limitations of the data.
“Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood,” it states.
Cris said Finn can decide for himself what surgeries he wants once he’s 18, and even if he changes his mind, she would support him.
But Fischer said that in 11 years, she only knows of one person who detransitioned. Even that client, she said, didn’t regret taking cross-sex hormones, but found that transitioning wasn’t for them.
She can’t count how many have told her that transitioning saved them.
Cris said the fact that some people regret their choices isn’t a reason to remove the choice for everyone.
“We all do things that we regret,” she said. “And we don’t have laws that then take those rights away from us.”
People who seek gender-affirming care generally do so to alleviate gender dysphoria — the distress arising from a mismatch between a person’s gender identity and their sex at birth.
The medical community recognizes individually tailored gender transition care as medically necessary for many transgender people who have dysphoria.
It has worked for Brendon.
He experienced gender dysphoria as his body developed through female puberty. He began wearing a chest binder and kept it on all the time.
“I felt like I had to have it,” he said. “I would sleep in it because of [my dysphoria].”
At 16, he tried to kill himself.
Now, three years of hormone therapy and one chest-masculinization surgery later, he is much more comfortable.
“I feel like I’m complete,” he said.
His story isn’t unusual.
Every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people. ... In addition, evidence has demonstrated that forgoing gender-affirming care can have tragic consequences."
— AMERICAN MEDICAL ASSOCIATION, in a 2021 letter to the National Governors Association
Transgender people are at elevated risk of depression and suicidality: A 2022 Canadian study of 6,800 teens found that trans teens were 7.6 times more likely to attempt suicide than teens who were not transgender. Studies on the psychological impacts of gender-affirming hormone therapy and surgery are limited, but some suggest that gender-affirming care reduces depression and suicidality along with gender dysphoria.
A 2022 study by researchers from the University of Washington and Seattle Children’s Hospital found that gender-affirming puberty blockers and hormones were associated with “60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up.”
Other studies have come to similar conclusions, and a 2020 Dutch study found that trans youth on a waiting list for gender-affirming care had poorer psychological well-being than non-transgender peers, but that the well-being of trans youth on puberty suppression medications matched or exceeded that of the non-transgender control group.
Fischer said gender-affirming care starts with gender-affirming therapy — nothing permanent.
Patients may take a new name and change pronouns, cut their hair short or grow it long, and wear clothes associated with a different gender.
From there, patients under 18 are evaluated by multiple health care professionals and must meet specific criteria before beginning medical interventions.
Once a patient enters the early stages of puberty, a doctor may prescribe puberty-blocking medications to prevent a trans girl from growing facial hair and developing a deep voice, and keep a trans boy from growing breasts — changes that can cause severe distress in transgender youth and are difficult and sometimes impossible to fully undo.
To start puberty blockers, Fischer said, patients must have begun puberty and need two recommendation letters from physicians and therapists.
“These are not prepubescent children,” Fischer said. “I know people who are 12, 13 years old, and they don’t qualify for puberty blockers yet because they haven’t developed enough, physically.”
Cross-sex hormone therapy promotes breast growth and female fat distribution patterns in trans girls and induces beard growth and voice lowering in trans boys.
Trans youth can’t start those medications until they’re in their late teens, Fischer said. Young children can’t get surgery, and it’s rare in teens under 18. Adults must also go through an additional multistep approval process to access it.
Many transgender Floridians access hormone treatments through nurse practitioners, not doctors, as the new law mandates.
The new law also requires patients to sign a consent form created by the Boards of Medicine and Osteopathic Medicine to continue receiving their medications, and when the law took effect on May 17, those boards had not yet drafted the required form, creating a catch-22 for doctors and patients.
Those provisions led some providers of transgender hormone replacement therapy, like Planned Parenthood, to suspend trans patients’ appointments and hormone prescription approvals until the boards, in June, approved an emergency six-month suspension of the new rules for trans patients who are continuing an existing prescription regimen.
Brendon said he has had trouble getting his prescription filled since the law was signed. “I’ve switched to like three different pharmacies now,” he said. “Since May.”
He gets his prescriptions from a doctor in Fort Myers, where he was originally diagnosed. But since moving to Palm Coast, he’s been seeing that doctor through telehealth. The law requires trans patients to see their doctors in person.
I have already observed a downturn in the mental health of all of my clients, across the board. Of all ages.”
— CYNTHIA FISCHER, licensed clinical social worker
Fischer said many trans adults are running into similar problems.
On social media, trans Floridians have been sharing information about how and where to buy black-market hormones. Some said they had been taking less than their prescribed doses, so they could stockpile medications and avoid being cut off suddenly as restrictions take effect.
Losing access to hormone therapy means facing unwanted physical changes.
If a trans person halts hormone therapy and hasn’t had surgery that removes their ovaries or testes, the sex hormones associated with their natal sex will become dominant again and reverse some effects of hormone therapy: Trans women might grow facial hair; trans men might begin menstruating.
Those who have had surgery wouldn’t have that problem, but would face medical complications such as decreased energy and bone density.
The changing laws and uncertainty about future access to care are straining Fischer’s clients.
“I have already observed a downturn in the mental health of all of my clients, across the board,” Fischer said. “Of all ages.”
At a June 30 meeting, the Board of Medicine and Board of Osteopathic Medicine finalized the new consent form the law requires. The boards also added new requirements for trans adults seeking to start or continue hormone therapy.
They now must have a thorough psychological evaluation by a psychologist or psychiatrist before starting, and then at least once every two years as long as they’re on the medication. The psychologist must present a letter of confirmation to the doctor who prescribes the hormone therapy.
The consent forms also require patients to sign an attestation that they’ll attend therapy.
Brendon called the Board of Medicine’s new requirements impractical.
He said he already underwent a psychological evaluation to begin transitioning, and requiring it every two years is a waste of time and money — especially when transitioning is already so expensive.
“I think they’re just amplifying all of the rules to make it almost impossible for trans people to get on HRT,” he said. “I’ve already had to prove myself, and now I just have to prove myself over and over and over again.”
Gender-affirming care bans around the country have been losing in federal court, and the Florida law’s restrictions for minors have already been challenged.
On June 6, U.S. District Judge Robert Hinkle, a federal judge in Florida’s northern district, granted a preliminary injunction of SB 254 to allow the three minors plaintiffs to receive puberty blockers and hormone therapy.
Hinkle wrote in his ruling that gender identity is real and that the plaintiffs were likely to prevail in the case. While gender dysphoria is complex to treat, he wrote, “There is now extensive clinical experience showing excellent results from GnRH agonists [puberty blockers] and cross-sex hormones.”
“If these treatments are prohibited, many patients will suffer needlessly,” he added.
“…The statute and the rules were an exercise in politics, not good medicine,” Hinkle wrote.
On June 20, a federal judge struck down a similar law barring gender-affirming care for minors — the first passed in the country — in Arkansas, calling the law unconstitutional and stating that forcing transgender minors through the pubertal changes associated with their birth sex could cause significant distress.
“Not all adolescents with gender dysphoria will live to age 18 if they are unable to get gender-affirming medical treatment,” U.S. District Judge James Moody wrote in the 80-page ruling.
And last week, federal judges blocked similar youth gender-affirming care restrictions in Tennessee and Kentucky.
As the legal fights proceed, Flagler Pride is linking trans people to resources.
Rivera said she worries about the law’s impact on trans youth.
“The suicide rate, that’s kind of what sticks in my mind — I don’t want to see that go up, especially in our community,” Rivera said. “Even if gender-affirming care is not available at this time, I want to make sure that our youth in our LGBT community have affordable therapy that they can reach out to if needed. … Because obviously, we can’t change the law overnight. But if we can save a life, I think that is most important.”
Brendon said the rhetoric from legislators is dehumanizing.
These people are elected to look out for their state and the people who live here — which includes transgender people, he said.
“They just don’t like us because we’re different,” he said. “But we’re not different. We’re human beings.”
