How to Keep Providing Gender-Affirming Care Despite Anti-Trans Attacks
Using lessons learned defending abortion, some providers are digging in to serve their trans patients despite legal attacks. The post How to Keep Providing Gender-Affirming Care Despite Anti-Trans Attacks appeared first on The Intercept.
It is a difficult time for the transgender community in Kentucky and those who support them. Less than two years ago, the state legislature, gripped with anti-trans hysteria, passed a ban on gender-affirming care for transgender youth. And in recent weeks, an onslaught of executive orders from President Donald Trump further imperiled access to gender-affirming care nationwide.
But Oliver Hall, director of trans health at the Kentucky Health Justice Network, knew how to respond. When the state decimated care for vulnerable youth, they helped families connect with providers out of state. When Trump released his anti-trans orders, Hall pressed to make sure those providers held the line.
“One of the first things we needed to do was call the clinics in other states, making sure they weren’t going to start preemptively complying, and stop providing care,” said Hall.
Immediate mobilization isn’t new to the staff at the Kentucky Health Justice Network. In addition to connecting LGBTQ+ people to services, it also serves as an abortion fund. When the Supreme Court overturned Roe v. Wade, it triggered a near-total abortion ban in the state — changing the landscape for abortion access almost overnight.
“We prepared to just kind of shift on a dime to be able to do more of the travel support,” Hall said.
As Hall and others in the reproductive justice and LGBTQ+ rights space know all too well, the assaults on transgender Americans are occurring against the backdrop of a wider war on bodily autonomy.
In 2025 alone, state legislatures have already passed 11 anti-trans bills, and roughly 614 bills are under consideration that could negatively impact trans and gender-nonconforming people. In 2024, 87 anti-trans bills were introduced in Congress, according to the Trans Legislation Tracker. Despite many conservatives’ attempts to create distance from anti-abortion politics, many of the states that moved to restrict access to gender-affirming care have some of the strictest abortion bans. The same president who issued a slew of executive orders targeting transgender youth also appointed the Supreme Court nominees who made it possible to overturn Roe. And the court he reshaped is expected to make a ruling on gender-affirming care for transgender youth this spring.
For decades, abortion providers, advocates, and funds have persisted under an ever-shifting and intentionally vague legal landscape dead set on, if not outright, banning abortion care, making it as difficult as possible for abortion providers to effectively and ethically treat their patients.
Now, providers who offer gender-affirming care find themselves in that same landscape, working tirelessly for their patients as the proverbial sand shifts constantly beneath their feet.
But if these fights are inextricably linked, so are the solutions.
“We have to be more imaginative of what care can or may need to look like.”
“In both the gender-affirming care space and abortion care space and again, broadly even immigrant health, we have to always be prepared for the ground to shift and change underneath us,” said Dr. Lakshmi Sundaresan, a family medicine physician in Michigan. “And I think that is the hardest thing.”
Sundaresan, who like many provides both abortion and gender-affirming care services, said that one lesson from both practices is that you have to be “imaginative.”
“Flexibility is important,” she said. “We have to be more imaginative of what care can or may need to look like.”
In abortion care, providers have shifted, where possible, toward counseling patients through self-managed abortions at home and sending pills by mail to states, Sundaresan said. Evidence suggests this strategy has been broadly effective. In the year after Roe was overturned, the number of abortions went up, with experts attributing it to a rise in telemedicine and self-managed medication abortions.
Thinking outside of the traditional approaches can help transgender patients, Sundaresan said. One way to do this is by looking for off-label uses of medications that might have gender-affirming side-effects, such as spironolactone, a blood pressure medication that also can block the production and action of testosterone. “The question would be, can we use a side effect or an alternative way that a medication works to help support folks in their gender journeys if there are restrictions placed on traditional hormone replacement therapy?” she said.
The answers may also lie outside of the health care space.
“Part of what imagination has to look like is how we can provide care – or people can manage their care — outside of interacting with the medical establishment,” she said.
Ongoing court battles over Trump’s anti-trans executive orders show how rapidly the legal landscape can and will change.
Before Trump returned to the White House, access to gender-affirming care varied widely by state, similar to abortion care since the Dobbs v. Jackson Women’s Health Organization decision. In recent years, more than two dozen states passed laws prohibiting care for trans minors, the most extreme of which criminalized prescribing puberty blockers as a felony. The Supreme Court is currently reviewing Tennessee’s law, in a case advocates hoped might set some guardrails at the state level. After oral arguments in December, many worry the conservative justices will uphold the law and give states wide latitude to restrict care.
In late January, Trump flexed federal power to target gender-affirming care for trans youth nationwide. He issued an executive order that threatened to withhold federal funding from hospitals, medical schools, and other institutions that offer gender-affirming care to anyone under 19 years old, even puberty blockers and hormone therapy. The president also directed the Justice Department to investigate doctors under the federal statute that criminalizes female genital mutilation, in coordination with state officials.
“It’s a coordinated, concerted effort to use trans people and trans youth in particular as political pawns,” said Alex Sheldon, executive director of GLMA, an association of medical providers that advocates for LGBTQ+ health equity, which joined a lawsuit challenging the executive order.
Many hospitals and clinics across the country quickly canceled appointments for young trans patients, who weren’t sure if they would ever be rescheduled.
This left “a patchwork landscape,” Sheldon said, “where your access to care not only depends on your geography but also institutional leadership and interpretation of the executive orders, rather than medical expertise.”
“Your access to care not only depends on your geography but also institutional leadership and interpretation of the executive orders, rather than medical expertise.”
In early February, coalitions of doctors, patients, parents, advocacy groups, and Democratic attorneys general filed two federal lawsuits: one in Maryland, the other in Washington state. By mid-February, two different judges granted temporary restraining orders that blocked the Trump administration from implementing the executive order provisions.
Doctors and other health care workers around the country were relieved, both for themselves and their patients.
“I felt like I could finally breathe again,” wrote a Seattle physician, Physician Plaintiff 1, who is one of three doctors suing the Trump administration under pseudonyms for fear of being targeted under the executive order, in a court filing in the Washington case.
Many were in tears at a staff meeting held just a few hours after the federal judge in Washington first blocked Trump’s order, Physician Plaintiff 1 wrote. Providers rushed to deliver good news to patients and their families, as the court orders gave some hospitals enough reassurance to continue offering care.
But the relief is temporary and subject to the uncertainties of litigation, including the Trump administration’s potential defiance of court orders. Both federal courts initially blocked the Trump administration’s plans until the end of February, then granted injunctions that will last until further developments in the case.
Despite the injunctions, the Trump administration still attempted to pull funding from some hospitals, and the plaintiffs in the Washington case have asked the court to hold the Trump administration in contempt for defying orders.
Amid the uncertainty, some health systems haven’t been willing to risk restarting their gender-affirming care programs. Others have been slow to give providers and patients concrete guidance about the evolving situation.
“We have not had clear communication around resuming care,” said D, a provider in Pennsylvania who spoke with The Intercept on condition of anonymity for fear of being targeted. D said their institution’s leadership and legal teams were still reviewing the executive orders and the court rulings blocking them.
“We’re put into this new role as future-tellers and legal experts,” D said. “I’m not sure we’re going to have a lot of clarity for some time, and possibly not until we have more final resolution of the lawsuits.”
Now that Trump has shown his playbook of leveraging federal funding to block care, doctors are weighing how to insulate themselves and their patients from this form of pressure.
“I have been trying to figure out if there is a place I could practice medicine that doesn’t accept federal funding,” wrote Physician Plaintiff 3 in another court filing in the Washington case, “or whether I could set up my own medical practice so that I could continue providing care to both my cisgender and transgender patients on an equal basis.”
Navigating the shifting legal risks is a key part of the puzzle for both abortion and gender-affirming care providers.
“These directives don’t carry legislative power, but it will take months to years to litigate them,” said Sundaresan.
The shifting landscape leaves providers at the whim of hospital and clinic executives. “It’s often hospital policy, not actual laws, that are dictating what kind of care we’re allowed to provide,” Sundaresan said.
One way to combat preemptive compliance in both the abortion and gender-affirming care space is by providing consistent and persistent messaging on what the laws actually mean, argued Hall, the Kentucky trans health director.
Not unlike much of the confusion that swept through the country in the early days after the Dobbs decision, Hall said that confusion about the state’s ban on gender-affirming care for transgender youth further hindered access to care.
“We had providers in the state who thought they couldn’t refer their patients out of state, providers, which is not true. We had therapists who thought they couldn’t provide gender-affirming mental health care, which was also not true. We had pharmacists who thought that they couldn’t dispense hormone therapy that was prescribed by an out-of-state prescriber, which was also not true,” said Hall.
In this case, research and messaging played a critical role in making sure that not just the medical establishment but also “the public, and particularly those families, understand that they still have options they don’t have to just give up,” they said.
Building resiliency among providers and advocates is also crucial when facing an opposition not averse to acts of violence.
Throughout the decades, anti-abortion protesters have reigned terror upon providers, bombing clinics and murdering doctors. In 1984, for example, there were 29 cases of arson, firebombing, or bombings against abortion clinics. And in 1993, Dr. David Gunn was infamously fatally shot by an anti-abortion extremist.
Today, while those threats still persist against abortion providers; hospitals and clinics that provide gender-affirming care now find themselves under that same violent spotlight. In 2022, a Massachusetts woman called in a fake bomb threat to the Boston Children’s Hospital in retaliation for their transgender youth services. “There is a bomb on the way to the hospital; you better evacuate everybody, you sickos,” she said, according to court records.
Mabel Wadsworth Center in Bangor, Maine, which provides a range of health care services, including abortion and gender-affirming care, counsels both staff and volunteers about the risks before they ever put on a uniform.
“There are inherent risks, unfortunately, in our culture with working at an abortion care provider, and now that also is associated with being a gender-affirming care provider,” said Aspen Ruhlin, the community engagement manager at the center. “We just make sure folks who are coming onto this staff are aware of what those risks are.”
Even with training, facing backlash and threats for work in both abortion and gender-affirming care spaces isn’t easy. But Sundaresan in Michigan said that she has no plans to stop.
“I don’t have any special coping skills,” she said. “I’m a person that has to sit with uncertainty, just like our patients have to sit with uncertainty.”
The post How to Keep Providing Gender-Affirming Care Despite Anti-Trans Attacks appeared first on The Intercept.
