The American Crisis in Gender-Affirming Care Access

1. Introduction: A Healthcare Crisis Unprecedented in Scope

- Scale and Scope of Restrictions -

The United States has become the world’s most restrictive developed democracy for transgender healthcare access, with 25 states banning gender-affirming medical care for youth as of July 2025, affecting over 120,400 transgender young people. Following the Supreme Court’s United States v. Skrmetti decision upholding Tennessee’s ban and President Trump’s Executive Order 14187 restricting federal support, these policies have created cascading impacts across healthcare systems, economies, and communities nationwide, with a 72% increase in suicide attempt rates among transgender youth in restrictive states and documented healthcare costs exceeding typical coverage expenses by factors of 100-300.

The legal landscape transformed dramatically between 2021 and 2025, evolving from Arkansas’s first ban to a complex patchwork where 40.1% of transgender youth now live under comprehensive restrictions. These bans extend beyond simple Medicaid exclusions, encompassing criminal penalties for healthcare providers (with six states imposing felony charges), professional license revocations, parental criminalization, facility restrictions, and insurance coverage prohibitions affecting public and private plans. The federal government’s withdrawal of supportive guidance and implementation of funding restrictions through multiple agencies has created additional layers of restriction that interact complexly with state laws.

Legal Restrictions Create Unprecedented Enforcement Mechanisms

The scope of current restrictions represents a fundamental shift in American healthcare regulation. Beyond the 25 states with active bans, federal Executive Order 14187 applies restrictions to all individuals under 19, prohibiting federal funding, sponsoring, or supporting gender transition procedures. Idaho leads in severity, imposing up to 10 years in prison for providers, while Missouri extends restrictions to adults, and Texas pioneered using child welfare investigations against supportive families.

Insurance restrictions affect multiple coverage types simultaneously. Twenty-seven states prohibit private insurance coverage for gender-affirming care, while federal restrictions impact Medicaid, TRICARE, and federal employee health benefits. The Centers for Medicare and Medicaid Services issued guidance in April 2025, reminding states that federal funds cannot support procedures rendering individuals under 21 “permanently incapable of reproducing.”

Federal restrictions expanded further in June 2025 when the Centers for Medicare and Medicaid Services posted rules to the Federal Register restricting ACA marketplace plans from including gender-affirming care as an essential health benefit. This limitation affects millions of Americans who purchase insurance through the healthcare exchanges, creating additional coverage gaps beyond the existing Medicaid, TRICARE, and federal employee benefit restrictions. However, enforcement mechanisms remain contested in federal courts.

Shield laws in 17 states plus DC attempt to protect providers and patients from out-of-state prosecutions. This creates a complex legal environment where healthcare provision legality depends on patient location, provider location, and the interaction between conflicting state laws. Professional licensing boards face pressure to revoke licenses even for providers following evidence-based guidelines, with some states mandating automatic revocation for violations.

State-Level Policy Recommendation: Economic Impact Assessment Initiative

States should conduct comprehensive economic impact assessments comparing litigation costs to actual coverage expenses. This analysis should include total costs of litigation, healthcare system disruption, interstate migration effects, provider workforce impacts, and long-term health cost projections. Georgia’s experience—spending $4.1 million to avoid $10,000 in annual coverage costs—demonstrates the fiscal irrationality requiring immediate policy reconsideration.

2. Healthcare Costs Reveal the Economic Paradox of Restriction Policies

- Economic Inefficiency and Public Cost -

States defending care restrictions have spent millions avoiding minimal coverage costs. Georgia alone spent $4.1 million on litigation since 2015, including settlements totaling over $2 million, while actual coverage would have cost approximately 0.01% of health plan budgets. Houston County, Georgia, paid nearly $1.2 million in legal fees fighting one case - almost three times the county’s annual physical and mental health budget - when coverage for all 1,500 health plan members would have cost approximately $10,000 annually.

The Congressional Budget Office estimated $700-800 million in “savings” over 10 years from removing federal Medicaid funding for gender-affirming care, affecting 180,000-185,000 transgender adults on Medicaid. However, these projections fail to account for increased emergency department usage, mental health crisis interventions, and long-term healthcare costs from delayed or denied care. States with restrictions report healthcare provider exodus, with recruitment difficulties creating additional economic strain on healthcare systems.

Economic impacts extend beyond direct healthcare costs. Families report spending up to $4,500 every six months for out-of-state medication access, with some quoted $26,000 every three months when insurance coverage is excluded. Interstate travel costs, including transportation, accommodation, and lost wages, create substantial financial burdens, particularly for rural and low-income families traveling 100-300 miles to access care in neighboring states.

State-Level Policy Recommendation: Economic Impact Assessment Initiative

States should conduct comprehensive economic impact assessments comparing litigation costs to actual coverage expenses. This analysis should include total costs of litigation, healthcare system disruption, interstate migration effects, provider workforce impacts, and long-term health cost projections. Georgia’s experience—spending $4.1 million to avoid $10,000 in annual coverage costs—demonstrates the fiscal irrationality requiring immediate policy reconsideration.

3. Public Health Data Demonstrates Severe Outcome Disparities

- Health Outcomes and Public Safety Impact -

Mental health statistics reveal the human cost of care restrictions. The Trevor Project documented a 72% increase in suicide attempt rates among transgender youth in the first year after anti-transgender laws were adopted. Overall, 26% of transgender high school students attempted suicide in the past year compared to 5% of cisgender male students, with rates reaching 42% lifetime attempts among transgender adults.

Access to gender-affirming care dramatically improves outcomes. Youth receiving appropriate medical care show 73% lower odds of suicidality and 60% lower odds of moderate or severe depression. A New England Journal of Medicine study following 315 youth over two years found sustained improvements in depression, anxiety, and life satisfaction with gender-affirming hormone therapy. Nearly 98% of youth who receive gender-affirming care continue treatment into adulthood with high satisfaction rates.

Violence and HIV statistics underscore additional health disparities. Transgender women are 66 times more likely to have HIV than the general population globally, with a 19.1% prevalence. In the U.S., transgender people are 2.2 times more likely to experience physical intimate partner violence and 2.5 times more likely to experience sexual intimate partner violence. School-based violence affects 40% of transgender students through bullying, compared to 14.8% of cisgender males.

Healthcare System Recommendation: Emergency Care Protocol Standardization

Healthcare systems must establish evidence-based emergency care protocols for transgender patients, including crisis intervention standards for youth experiencing suicidal ideation, emergency hormone therapy continuation during hospitalization, mental health crisis response with transgender-competent care, and family support integration. The 26% suicide attempt rate among transgender high school students creates immediate emergency care obligations.

4. Legal Battles Generate Millions in Unnecessary Public Expenses

- Legal and Financial Consequences -

Litigation costs across multiple states reveal the financial burden of defending discriminatory policies. Montana faces $725,916 in attorney fee claims from successful challenges, while North Carolina spent over $1 million in attorney fees defending restrictions. The pattern repeats across states: expensive legal defenses for policies that actuarial analyses consistently show would have minimal financial impact if simply implemented.

Administrative costs compound legal expenses. Texas’s child abuse investigation directive created massive bureaucratic strain, with Department of Family and Protective Services employees reporting the agency was on the “brink of collapse” from investigation demands. Federal agencies redirect resources to implement and defend executive orders, while states establish new enforcement mechanisms requiring ongoing funding.

While the Supreme Court’s Skrmetti decision allowed state bans to proceed, it hasn’t ended litigation. Seventeen states face active lawsuits, and federal appeals courts address various constitutional claims. State-specific challenges based on state constitutional provisions continue in Montana and elsewhere, ensuring ongoing legal costs regardless of federal precedent.

Congressional Policy Recommendation: Interstate Healthcare Mobility Protection Act

Congress should pass federal legislation protecting healthcare providers and patients crossing state lines for legal medical care. This should include shield law protections for providers treating out-of-state patients, insurance portability requirements, professional licensing reciprocity, and criminal/civil immunity for legal interstate healthcare provision. Houston County’s $1.2 million legal costs to fight $10,000 in coverage demonstrate fiscal urgency.

5. Intersectional Impacts Intensify Existing Healthcare Disparities

- Healthcare System Disruption -

Transgender youth of color face compounded discrimination and barriers. 75% of transgender homicide victims in 2024 were people of color, predominantly Black transgender women. Black and Hispanic transgender youth experience higher rates of family rejection, with 40% of LGBTQ youth kicked out or abandoned due to their identity. These youth are overrepresented in foster care, where 30% identify as LGBTQ+ despite representing only 9.5% of the general population.

Rural transgender populations encounter severe access barriers even before restrictions. 24% travel 25-75+ miles for primary care, with some traveling up to 8.5 hours due to provider scarcity. Rural areas often lack LGBTQ-affirming resources and face more hostile social climates. States with bans have only one-third the number of adolescent medicine providers compared to states without restrictions, creating vast care deserts.

Youth homelessness disproportionately affects LGBTQ+ individuals, who have 120% higher risk of experiencing homelessness and comprise 20-40% of homeless youth. Family conflict remains the primary cause, with 55% of youth who ran away citing mistreatment related to LGBTQ identity. Housing instability correlates with dramatically increased mental health risks, including 3.7 times higher odds of suicide attempts.

Educational outcomes suffer under hostile policies. Transgender youth are 3.7 times more likely to experience bullying and 3.3 times more likely to miss school due to safety concerns. Using chosen names in school reduces suicidal behavior by 56%, while supportive school policies significantly improve mental health outcomes. However, 19 states have restricted discussions of gender identity in curricula, removing protective educational environments.

State Policy Recommendation: Comprehensive Shield Law Expansion

The 17 states plus DC with existing shield laws should coordinate to create comprehensive protection networks. This includes standardizing shield law language, establishing interstate compacts for healthcare provider licensing, creating coordinated legal defense funds, and developing information-sharing systems. Target states for new shield laws include Nevada, New Mexico, and Arizona (completing the Western corridor) and Virginia and North Carolina (strengthening Southeast access).

6. America Stands Alone Among Developed Nations in Criminalizing Care

- International Standing and Comparison -

International comparison reveals the United States as an unprecedented outlier. While some European countries like the UK, Sweden, and Finland have adopted more cautious medical approaches to youth care based on evidence reviews, none criminalize healthcare providers or target families with child welfare investigations. The U.S. remains the only developed democracy imposing felony charges on doctors for providing evidence-based care.

Countries with protective policies demonstrate superior outcomes. Malta, ranking first globally for transgender rights, reports zero transgender murders from 2008 to 2022 and provides comprehensive healthcare through its national system. Argentina’s self-determination model includes full healthcare coverage without age restrictions. The Netherlands, often considered the gold standard, shows transgender youth achieving mental health outcomes indistinguishable from cisgender peers when accessing appropriate support.

The Asher & Lyric Global Trans Rights Index ranks the United States 40th globally, behind most developed nations and many developing countries. The U.S. approach of legislative bans with criminal penalties contrasts sharply with evidence-based policy changes elsewhere. Even countries implementing restrictions do so through medical guidelines and professional standards, not criminal law.

Human rights organizations unanimously condemn U.S. restrictions. Human Rights Watch’s 2025 report calls the U.S. approach “unprecedented in its scope and severity,” documenting systematic targeting of healthcare providers, families, and civil society organizations. UN human rights bodies emphasize that denial of healthcare violates international treaty obligations, while the WHO develops comprehensive guidelines recognizing gender-affirming care as medically necessary.

Federal Policy Recommendation: International Alignment Initiative

The State Department and HHS should coordinate with international partners to align U.S. policy with evidence-based approaches used by peer nations. This includes reviewing successful models from Malta, Argentina, and the Netherlands, engaging with WHO guideline development, and restoring U.S. leadership in global LGBTQ+ health initiatives. The current ranking of 40th globally undermines American diplomatic credibility.

7. Barriers and Access to Care

Geographic Barriers Transform Healthcare into Cross-Country Odysseys

The emergence of vast care deserts forces 55% of transgender individuals to travel at least 10 miles for transition-related care, with more than 1 in 5 transgender people of color in rural areas traveling over 100 miles. The South and Southeast’s 14-state contiguous ban zone creates the nation’s largest care desert, while Midwest restrictions particularly impact rural populations with already limited healthcare access.

Provider distribution analysis reveals severe shortages exacerbated by legal restrictions. Missouri’s comprehensive ban created massive patient flows into Illinois, overwhelming border-state providers. New Mexico lost 30% of physicians in four years and faces the second-largest projected physician shortage by 2030. Multiple university-based gender clinics closed in Texas, Missouri, and other restrictive states despite academic medical center protections.

Wait times stretch beyond reasonable healthcare standards, with initial appointments taking 4-18 months and surgical consultations adding 6-12 months more. Some providers report waitlists indefinitely closed due to overwhelming demand from out-of-state patients. The strain forces established patients to reduce visit frequency, disrupting continuity of care essential for monitoring hormone therapy and addressing complications.

Telehealth restrictions compound geographic barriers. Tennessee explicitly prohibits gender-affirming care via telehealth, while cross-border telehealth faces legal complications when providers and patients operate under conflicting state laws. Despite 51% of rural trans adults receiving mental health services via telehealth, medication management and physical examinations still require in-person visits, maintaining travel burdens.

Healthcare System Recommendation: Emergency Infrastructure Investment

Immediate federal funding of $50 million should support healthcare provider capacity in protective states experiencing a patient surge. This includes provider pipeline programs for gender-affirming care specialists, clinic capacity expansion for overwhelmed facilities, rural access initiatives through mobile clinics and telehealth, and provider retention incentives through loan forgiveness. Current 4-18-month wait times create dangerous delays requiring immediate intervention.

Underground Networks Emerge as Healthcare Systems Fail

The systematic denial of care has created informal support systems outside traditional healthcare. 54% of transgender patients report educating their doctors about trans healthcare, leading to peer-to-peer networks sharing provider referrals and vetting information. Online communities become critical lifelines for accessing care strategies and emergency resources.

The Southern Trans Youth Emergency Project, operating across 16 states, provides $500 emergency grants for travel expenses and connects families with out-of-state providers. Community health organizations serve as bridges between patients and willing providers, while anecdotal reports indicate increased hormone sharing during shortages. Some patients resort to medical tourism, traveling to Mexico or other countries for surgical procedures unavailable domestically.

Gray market activities reflect desperation rather than choice. DIY hormone therapy increases when formal healthcare becomes inaccessible, despite significant risks. Underground surgery referral networks share information about providers willing to work outside traditional systems. While providing crucial support, these informal networks cannot replace comprehensive, regulated healthcare and expose vulnerable populations to additional risks.

Federal Policy Recommendation: Comprehensive Telehealth Protection Framework

Establish robust telehealth protections transcending state boundaries through interstate telehealth licensing compacts, prescription portability protocols for hormone therapy, emergency consultation networks, and insurance coverage requirements regardless of provider location. With 51% of rural transgender adults relying on telehealth for mental health services, federal action is essential to prevent healthcare access collapse.

8. Policy Solutions: A Comprehensive Response Framework

Federal Priorities

1. Executive Order Review and Revision (0-90 Days)

• Establish an interagency task force (HHS, DOD, OMB, VA)

• Commission National Academy of Medicine evidence review

• Assess constitutional implications with DOJ

• Develop revised guidance aligning with medical standards

2. Interstate Healthcare Legal Framework (0-90 Days)

• DOJ opinion on interstate commerce protections

• CMS guidance on cross-state care coordination

• FTC guidance on insurance coverage across state lines

• Treasury guidance on health savings account usage

3. Emergency Healthcare Access Protection (0-90 Days)

• EMTALA guidance for transgender patients

• Crisis intervention protocols for federal facilities

• Emergency Medicaid coverage clarification

• VA emergency care protocols

4. Congressional Legislative Action (90-365 Days)

• Pass the Equality Act for comprehensive civil rights protections

• Restore Medicare/Medicaid coverage for evidence-based treatments

• Protect federal employee health benefits

• Restore TRICARE coverage for military families

State-Level Actions

5. Shield Law Network Expansion

• Standardize protective language across states

• Establish interstate healthcare compacts

• Create coordinated legal defense funds

• Target expansion: Nevada, New Mexico, Arizona, Virginia, North Carolina

6. Healthcare Infrastructure Investment

• $50 million provider pipeline programs

• Emergency clinic capacity funding

• Rural mobile clinic initiatives

• Provider retention incentives

7. Economic Impact Assessments

• Compare litigation costs to coverage expenses

• Evaluate provider workforce effects

• Review interstate legal conflicts

• Assess emergency care utilization increases

Healthcare System Transformations

8. Emergency Care Standardization

• Crisis intervention standards for transgender youth

• Emergency hormone therapy continuation protocols

• Mental health crisis response training

• Family support integration guidelines

9. Provider Education Expansion

• Medical school curriculum integration

• Residency/fellowship specialized tracks

• Continuing education requirements

• Rural provider support networks

10. Insurance System Reform

• Interstate portability for legal treatments

• Network adequacy requirements

• Prior authorization standardization

• Coverage parity enforcement

9. Looking Forward: Unprecedented Challenges Demand Innovative Solutions

- Conclusion -

The current crisis in gender-affirming care access represents the intersection of multiple system failures: legal, medical, economic, and social. With 120,400 youth directly affected by bans and countless more facing restricted access, the human cost continues mounting. The 72% increase in suicide attempts in restrictive states translates to preventable deaths and lifelong trauma for thousands of young people and their families.

Economic inefficiency characterizes the current approach, with states spending millions defending policies that would cost thousands to implement humanely. The broader economic impacts - healthcare provider exodus, interstate migration, lost productivity, and increased emergency care costs - create fiscal drains far exceeding any perceived savings from restricting care. International comparison reveals the U.S. approach as uniquely punitive and demonstrably ineffective at improving health outcomes.

The path forward requires recognizing gender-affirming care as evidence-based medical treatment that deserves protection from political interference like other healthcare decisions. The stark disparities in outcomes between supportive and restrictive environments, documented across multiple studies and populations, make clear that access to care represents a matter of life and death for transgender Americans. As legal battles continue and political landscapes shift, the fundamental truth remains: comprehensive, accessible gender-affirming care saves lives, while restrictions create preventable suffering and death at enormous public cost.

Current restrictions on gender-affirming care represent a convergence of policy failures that impose substantial public costs while worsening health outcomes. The 72% increase in suicide attempts in restrictive states translates to preventable deaths, while states spend millions defending policies that comprehensive evidence shows to be medically unnecessary and economically inefficient. With the United States as an international outlier in criminalizing evidence-based healthcare, policymakers face urgent pressure to address a crisis that affects over 120,400 youth directly and undermines broader healthcare system stability.

The path forward requires immediate action at federal, state, and healthcare system levels. The policy recommendations outlined in this brief provide concrete, achievable steps based on evidence, economic analysis, and successful international models. Implementation requires coordinated action with accountability mechanisms ensuring measurable progress toward evidence-based, fiscally responsible policy solutions.

10. References

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C

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D

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E

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F

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G

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H

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K

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M

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N

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O

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R

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S

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T

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U

UCLA Law: https://law.ucla.edu/academics/centers/center-reproductive-health-law-and-policy/shield-laws-reproductive-and-gender-affirming-health-care-state-law-guide

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W

WHO (World Health Organization): https://www.who.int/news/item/28-06-2023-who-announces-the-development-of-the-guideline-on-the-health-of-trans-and-gender-diverse-people

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