Executive Summary
Gender-affirming care (GAC) refers to a wide range of treatments sought by transgender youth, adults, and their families. In recent years, many states have moved to restrict access to this care, particularly for transgender minors, while other states have increased their legal protections to protect access to this care. This study aimed to understand the experiences and challenges facing GAC providers in states that, at the time of data collection, had not passed any legislation limiting or banning the provision of GAC to youth or adults. We specifically sought to engage providers who were less vulnerable to legal action but also potentially more burdened as they continue to provide GAC to a wide range of individuals, including those coming from out of state, because of new barriers to access in their home states.
Using a mixed-methods, anonymous survey that was partially informed by focus groups with GAC providers, we examined how GAC providers in states without laws restricting access to care were being impacted both professionally and personally by bans in other states and corresponding declines in GAC provision in various states and communities. We focused on multiple impacts, including impacts on medical practices and institutions, clients, providers themselves, and the profession more broadly. We also assessed responses to these impacts taken by providers and their institutions.
Our non-representative sample of 133 GAC providers included those who worked at least partly with youth (82%) and those who worked with adults only (18%). It included mental health providers (e.g., social workers, psychologists; 55%) and medical providers (e.g., physicians, nurses, physician assistants; 45%). Most participants (80%) were LGBQ, and 44% were transgender.
Key Findings
Characteristics of Survey Respondents
Demographics
- Most (80%) participants were LGBQ, and 20% were heterosexual. Just over half of participants were cisgender, and 44% were transgender or nonbinary.
- In terms of race and ethnicity, most participants were white (87%). About five percent identified as Asian (4.5%), 2.3% Hispanic, 2.3% Latino/a/x, 1.5% Black, 0.8% American Indian/ Alaska Native, and 3.8% as something else (e.g., Middle Eastern, multiracial).
- The largest number of participants worked in Massachusetts (29%), Minnesota (15%), California (15%), New York (11%), Illinois (7%), and Oregon (5%), with smaller numbers (1-3%) in Colorado, Connecticut, Delaware, Maryland, Michigan, New Hampshire, New Jersey, Pennsylvania, Rhode Island, Vermont, Virginia, Washington, Wisconsin, and Washington, D.C.
Types of GAC Offered and Professional Responsibilities
Client Population
- Almost all participants (97%) provided care for adults, and the majority of participants (82%) served at least some youth. Three percent served youth only.
Provider Responsibilities
- All but one provider in the study participated in direct patient care (99%), and the average amount of time spent in patient care was 66%.
- Most respondents (84%) did at least some administrative duties.
Workplace Setting and Focus of Practice
- Approximately 60% worked in a clinical care setting (e.g., medical school, clinic, health center), and 40% worked in a therapy/counseling center (e.g., individual or group therapy practice, college counseling center).
- Almost three-quarters (72%) said that their practice/clinic was LGBTQ or transgender-focused, with 8% saying it was not and 20% indicating that their answer was complicated.
Impacts of Recent Legislation
Impact on Practices and Institutions
Burden on Workload and Demand for Services
- Some providers reported very long waitlists, with 4% saying that over 300 people were on their waitlists and 2% saying 101-300 were on their waitlists. Most (81%) said 0-20 people were waiting, and 12% said they had between 21-100 people.
- Many providers were seeing out-of-state clients, with some reporting that they saw hundreds of people from other states.
- Nearly one-third (31%) of providers said that their out-of-state clients were seeking care because of restrictive laws in their states.
Demand for GAC
- Over half of providers reported that the demand for GAC among adults (54%) and youth (55%) at their practice had increased as a result of recent legislation limiting access to care.
- Only 1% said that demand for GAC had decreased among youth, and no providers reported that demand had decreased among adults.
Health Insurance Coverage for GAC
- Over half (53%) of participants said that they had encountered issues or changes with regard to insurance coverage of GAC over the past few years.
Impact on Clients
Personal Impacts and Access to Care
- Nearly half of providers (48%) reported growing waitlists for youth, and 38% reported increasing waitlists for adult clients.
- Forty-one percent of providers said that their youth clients expressed hesitancy around accessing GAC. Forty-two percent said the same about their adult clients. About three-quarters of participants said their youth clients (72%) and adult clients (77%) were more worried about their continued ability to access care.
- Many also said that their youth (43%) and adult (61%) clients expressed concerns over the privacy and security of their personal information related to accessing GAC.
- Two-thirds (67%) of youth clients and their families were paying more attention to where they chose to live or were considering moving.
Impact on the Profession of GAC
- Almost three-quarters (72%) of providers said that the rise in legislation around GAC had increased visibility and focus on GAC providers and services.
- Around two-thirds of participants said that they perceived a recent increase in burnout among providers (66%) and increased worry about criminal liability and penalties (62%).
- At the same time, over three-quarters of participants believed that providers experienced an increased commitment to providing such care (79%) and increased solidarity among care providers (77%) due to the recent rise in legislation related to GAC.
Impact on Providers
Victimization and Safety
- About one-quarter (26%) of providers had been personally threatened online, and more than one in 10 had been threatened in person (13%) or via phone (16%).
- Over one-quarter said that their place of employment had received threats related to their provision of GAC (29%).
Health and Well-Being
- About 80% of respondents reported increases in stress related to the rise in legislation around GAC, more than three-quarters reported increases in anxiety (77%), and more than half reported increases in depression (53%).
- More than one-third reported more difficulty sleeping (36%), and more than one-quarter reported increased physical challenges (26%) as a result of the increase in legislation.
Professional and Personal Life
- Participants reported increased worry about others due to the increase in anti-transgender legislation. For example, 79% of respondents have spent more time worrying about the health and well-being of their patients as a result of increased legislation related to GAC, and 65% have spent more time worrying about the health and well-being of their more vulnerable colleagues, such as transgender colleagues.
- Nearly 40% of providers spent more time worrying about their financial stability (38%), and 6% had lost professional opportunities due to their visibility as a provider of GAC. About 20% questioned whether they had made the right professional choice to enter the field of GAC (19%).
Stress, Burnout, and Job Satisfaction
- Regarding burnout, on average, participants felt personally burned out or experienced work burnout approximately half of the time (55% and 49%, respectively).
- Lower levels of burnout were experienced in their actual interactions with clients. On average, participants experienced client burnout 29% of the time.
- Participants were, on average, somewhat satisfied with their jobs.
Support from Coworkers and Institutions as a GAC Provider
- Although most participants felt very supported (62%) or somewhat supported (20%) by their employers as a gender-affirming care provider, 12% did not feel this way. More specifically, 7% said they received ambivalent/mixed support, 4% said they felt not very supported, and 1% said they felt not at all supported. Six percent did not answer the question because it was not applicable to them (e.g., because they were self-employed and/or their own “boss”).
Additional Challenges as a Transgender or Nonbinary Provider
- 100% of transgender and nonbinary participants said that being transgender or nonbinary made providing GAC more complicated.
Actions Taken in Response to Recent Legislation
Changes in Employer Actions Related to Provision of GAC
- Many providers reported changes in employer practices, such as changes related to the visibility of GAC services. Overall, 65% reported one or more actions that enhanced the visibility and feasibility of GAC provision, including increasing staff who provide GAC and increasing visibility around the provision of GAC. Another 47% reported actions aimed at supporting the well-being and safety of GAC providers.
- This includes over a quarter (28%) of providers who reported that their employer had increased security in their building to manage existing or possible threats.
- By contrast, 27% of participants reported that their employer had taken one or more actions to reduce their visibility around the provision of GAC.
Changes to Scope of Services
- Thirteen percent of respondents indicated that they have had to apply to new funding streams and grants to provide GAC; 4% have had budget cuts affecting their ability to provide GAC.
- Similar percentages of providers said that they increased the types or scope of GAC they provided (12%) or reduced the types or scope of GAC they provided (9%) as a result of recent legislation.
- Eight percent (8%) said their job responsibilities had changed, and 23% said they were now working with external organizations to coordinate access to GAC.
Changes in Approach to Care
- Over half (57%) said their approach to counseling youth, adults, and families had changed due to recent legislation.
- GAC providers described spending more time discussing risks, protections, and safety, including potential moves out of the state or country and how to protect their personal information, obtain legal documentation, be safe in public, and maintain access to gender-affirming care.
- GAC providers also spent much more time discussing community support and resources.
Changes to Visibility as a Provider
- Nearly half (47%) of participants had sought to become more visible as a GAC provider as a result of the recent rise in legislation around GAC. Just 14% had sought to become less visible as a provider over the past few years.
- Several providers reported seeking to increase professional visibility while minimizing personal and family visibility.
Actions Taken by Providers Personally
- Participants reported taking various actions to help deal with the rise in recent legislation over the past few years. Close to or more than half of the participants were spending time with and seeking support from family and friends (59%), setting boundaries between work and home (51%), exercising/meditating (48%), and engaging in advocacy work on behalf of transgender youth or adults (51%).
- One in five (20%) were considering leaving their current job.
- Many also reported taking actions to protect their safety. Over one-third (39%) were trying to decrease their visibility online, and 30% removed private information about themselves or their family on the internet.
- Some types of providers were more likely to take protective actions. For example, providers who served youth were more likely than those who served adults only to take steps to remove their personal information online (34% versus 12%). They were also more likely to install security systems than those who served adults only (14% versus 0%). Transgender providers were more likely than cisgender providers to take steps to remove their personal information online (38% versus 24%).
Thinking About the Future
Thinking about the future of GAC, providers reported many concerns, including:
- Further restrictions on care
- Funding or resource challenges
- Difficulties facing their state, community, or clinic in managing a continued influx of out-of-state patients
- Concerns about their own personal safety
- Escalation of mental health challenges and suicidality among transgender people
Some providers also spoke about concerns over their own personal capacity to provide GAC in the future.
- At the time of the study, 44% of respondents were not at all worried, and 29% were not very worried about job security. Cisgender providers were less likely to be concerned about their jobs than transgender providers (78% vs. 67%).
- When asked what advice they would give to future health professions students interested in GAC, most emphasized the rewards of providing such care. However, some also emphasized challenges alongside such rewards.