Laws restricting gender care spark an epidemic of overcompliance

November 30, 2023 Queer Forty Staff 7 min read

The Campaign for Southern Equality’s Southern Trans Youth Emergency Project has provided navigation resources and $300,000 in emergency funding to 600+ families and individuals impacted by gender affirming care bans, and is also mapping reports of overcompliance across the region.

Nearly every state in the South now has a law on the books restricting access to gender-affirming healthcare for transgender youth, following a barrage of new legislation that passed and became law in 2023 during the most harmful legislative session to the LGBTQ+ community in modern history. The South, home to approximately one-third of all LGBTQ+ Americans, has been the epicenter of these political attacks. An estimated 90% of transgender youth in the South live in a state that has passed a ban, and half of those bans are in effect right now. Click here for a map of where bans have passed and where they are in effect or on hold pending litigation.

In response to this crisis, the Campaign for Southern Equality (CSE) has been leading the Southern Trans Youth Emergency Project, which serves as a resource center for families, helping them access out-of-state healthcare options so their child can continue to receive uninterrupted care, and providing emergency grants of $500 to defray the financial burdens resulting from these bans. Since the launch of the project in March, CSE has distributed more than $300,000 in direct emergency grants to more than 600 families and individuals in twelve Southern states. STYEP is currently serving 83% of transgender youth nationwide who live in a state with a ban.

With these bans now in effect across the region, clear patterns of “overcompliance” with the laws are emerging, compounding the harms of the bans well beyond the letter of the law.

Rev. Jasmine Beach-Ferrara (she/her pronouns), Executive Director of the Campaign for Southern Equality, said: “It’s hard to overstate the level of chaos and stress that these cruel bans on life-saving care for transgender youth are causing on the ground. The bans are intentionally vague and their implementation is leading to far-reaching damage. We’ve seen medical institutions shutter services that they are not legally required to, and we’ve seen illegal denials of pharmaceutical care.

“This is legislative malpractice that is causing mounting harms to transgender young people and their families. Our team at the Campaign for Southern Equality is committed to working alongside our partners to help every family we can access the care that they need and deserve.”

The following types of overcompliance have been reported by families across the South:

Pharmacies are refusing to fill prescriptions, even when they can do so legally: In several states, families have reported an unpredictable patchwork of denials and service provision from pharmacies that is exceedingly difficult to navigate: For example, two pharmacy locations that are part of the same chain have provided conflicting answers about whether they can fill a prescription; and two pharmacists at the same store have provided conflicting information, with one refusing to fill a prescription and another filling it. In Alabama, where the law (which does not restrict the “dispensing” of medication) is not currently in effect, several pharmacies have told parents that they would no longer fill prescriptions of gender-affirming medication for transgender youth. Similarly, while North Carolina’s law allows trans youth who began a “course of treatment” prior to August 1, 2023 to continue receiving that care in perpetuity, CSE has tracked reports of pharmacies refusing to fill prescriptions for youth who should be allowed to continue care without interruption. In Tennessee, where youth in care prior to July 1 are allowed to continue care through March 2024, this pattern held, with different stores from the same chain saying they could, or could not, fill a prescription.
Medical providers and institutions that are not covered by the law are denying care: In Mississippi, a specific provision forbidding “aiding and abetting” people from helping youth access gender-affirming care (without defining what that means) seems to have had a chilling effect on many different providers, even those who do not offer transgender-related healthcare. This spring, several youth patients reported being turned away from being established at a pediatric office when they were simply seeking treatment for asthma. Other bans have caused some parents to hesitate about taking their child to a mental health provider, largely out of confusion about what is and what is not illegal (no state currently bans mental healthcare providers from speaking about gender identity and gender dysphoria).
Populations that are exempt from the law are experiencing denials of care: In several Southern states, parents of intersex children have reported interruptions or outright denials of care, despite the laws in those states explicitly providing an exemption for intersex youth that allows gender-related care, such as hormone therapy, to continue.
Providers are terminating care earlier than necessary: Some of the state laws have a clause that allows transgender young people already receiving care to continue receiving that care, usually through a certain deadline. For example, in Tennessee patients enrolled in care by July 1, 2023 are legally allowed to remain in care until March 31, 2024. In Missouri, patients enrolled in care by the end of October 2023 are legally allowed to remain in care through October 2027. There are similar exemptions, some of which explicitly declare this period to be a “tapering off” period, in Louisiana, Georgia, Kentucky, and North Carolina. Functionally, however, many providers in these states – including Tennessee (most notably Vanderbilt University Medical Center) and Missouri (most notably Washington University in St. Louis), ceased providing care for all youth patients as soon as the law took effect.
Once providers pause provision of care, they often do not resume care, regardless of litigation developments: The ban on gender-affirming care for youth never took effect in Arkansas because of a court ruling that found the ban to be unconstitutional. But major providers in the state stopped accepting new patients in anticipation of the law’s 2021 effect date, and they have yet to resume the initiation of new patients, despite two years of ongoing litigation.
Even without passing outright bans, states are infringing on care for trans youth: Overzealous Attorneys General, often working in step with far-right activists, can intimidate providers of gender-affirming care. In May, following threats of an investigation by the Texas Attorney General but prior to the passage of SB14 in Texas, Del Children’s Medical Center in Austin stopped providing transgender-related care for their youth patients, leaving hundreds of families without care. Similarly, in South Carolina a 2022 budget proviso targeted the Medical University of South Carolina, leading to the closure of their gender-affirming care clinic and requiring dozens of patients to initiate care elsewhere in the state.
Overcompliance with scheduling that is delaying care: In North Carolina, the ban prohibits medical providers from initiating hormone therapy, puberty blockers, or surgery to transgender people under 18. However, some providers are taking a strict approach to this – at least one family reported that their 17-year-old is not even allowed to schedule an appointment for a transgender-related medical procedure until their 18th birthday. Wait lists for the provider are longer than 12 months right now – so, functionally, the young person will not be able to visit the provider until they turn 19 years old, effectively delaying care beyond what the law requires.
Providers in states without bans are refusing to provide care to out-of-state patients: We have seen several reports of providers in New Mexico and Kansas, where there is no ban on gender-affirming care, cancel or refuse to book appointments with families traveling from states with a ban. There is no provision in these laws blocking families from crossing state lines to access care.
Providers in states without bans are restricting their own services: Earlier this year Colorado Children’s Hospital announced that it would no longer offer gender-affirming surgery to adults. The hospital had never offered surgery to minors.

Rev. Beach-Ferrara continued: “A fringe but vitriolic right-wing movement, including lawmakers in states across the South, are essentially using intimidation tactics to pressure medical providers and institutions into further restricting access to care. As advocates fight these laws in the courts and on the ground, we urge medical providers, pharmacies, and communities at large to not make this crisis worse through overcompliance with the law. And we want families to know that care is accessible and help is available – and our community is here to support, join in solidarity with you, and help you navigate this crisis.”

Families of transgender youth in Southern states who need support accessing gender-affirming care should contact the Southern Trans Youth Emergency Project at www.southernequality.org/styep.

Source: Southern Equality