Last August, an anonymous caller left a voicemail at the National LGBTQIA+ Health Education Center at the Fenway Institute, saying he was coming to "handle" a clinician providing youth with gender-affirming care associated with the clinic.
Three months later, the FBI charged the caller, a Texan, for issuing an interstate threat. Dr. Alex Keuroghlian, the Director of the Division of Public and Community Psychiatry at Massachusetts General Hospital who also works at the Fenway Institute, said sister centers have also had anti-trans groups posing as donors so they can tour the health center and discreetly videotape staff and community members.
In the past few years, anti-trans groups have been threatening children's health centers offering gender-affirming care across the country. A series of bomb threats called in at Boston Children's Hospital ultimately caused the facility to temporarily shut down. Other threats were reported at Children's National Hospital in D.C., Vanderbilt University Medical Center in Nashville and Akron Children's Hospital outside of Cleveland, Ohio.
In Texas, the climate has gotten so toxic that some gender-affirming healthcare providers are leaving the state. Nationally, health centers are removing personal identification information from their websites to protect providers from physical violence.
"Direct threats against clinics providing gender-affirming care and LGBTQ+ care in general have been increasing in the last two years," Keuroghlian told Salon in a phone interview.
A new survey published today in the Journal of the Endocrine Society documents just how common threats like these are. Among 125 pediatric endocrinologists offering gender-affirming care surveyed, nearly 17% reported experiencing threats to their personal safety and 60% said they were concerned about being sued for providing care, reported study author Dr. Stephanie Roberts, an endocrinologist at Boston Children's Hospital.
"For both of these factors, this was significantly increased among pediatric endocrine providers who provided gender-affirming care in a state with a proposed and/or passed ban on gender-affirming medical care," Roberts told Salon in an email.
Research shows gender-affirming care improves the mental health and well-being of youth who are transgender, gender diverse or nonbinary. Significantly reducing dysphoria, treatment through social transitioning, puberty blockers or hormone therapy can be lifesaving for children. More than 30 medical organizations have issued policy statements supporting gender-affirming care. Misinformation online often suggests health centers are providing gender-affirming surgical care to children, but this is typically not recommended until age 18.
As of this writing, 22 states have passed legislation intended to ban gender-affirming care for teens, according to the HRC. Restrictions are still being contended in states like North Dakota, Georgia and South Carolina.
In the survey, 28% of providers who practiced in states with restrictions in place for gender-affirming care reported that they feared providing transgender healthcare would negatively impact their career and 26% reported that their institution was concerned with them engaging with media.
"There are bills that have been proposed to make provision of different types of gender-affirming care misdemeanors, civil or felony offenses, so we're literally talking about healthcare professionals going to prison for providing medically necessary, evidence-based care," Keuroghlian said. "Even if [laws] are not passed or enforced, they do create a culture in which transgender and gender-diverse people are dehumanized and instill reticence among clinicians when it comes to delivering this care."
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In the survey, one provider wrote, "We and our patients are living in consistent fear." Another said parents are sometimes so afraid of being reported to Child Protection Services for taking their children to the clinic that physicians are seeing an increased number of no-shows.
"The amount of political pressure against my transgender patients has been extremely detrimental to my mental and physical health," one respondent wrote. "I have never been ill so much. I am terrified every day by what my state will do to our transgender children."
In October 2022, the American Medical Association, American Academy of Pediatrics and the Children's Hospital Association called on the Department of Justice to investigate threats made to children's medical centers. They also called on social media companies to halt misinformation campaigns they said were contributing to the prevalence of threats.
Much like reproductive health bans increase the distance at which people seeking abortions must travel to get treatment, bans on gender-affirming care create additional financial and physical barriers for youth seeking care that can effectively strand families who do not have the means to travel out of state to receive treatment. In states like Florida, some bills even restrict access to gender-affirming care provided from out of state, with provisions setting additional limits on telehealth.
In the survey, even providers in states without gender-affirming care bans reported experiencing threats of physical violence or concerns about legal action taken against them. Patchwork bans across the country can cause confusion among patients and providers. After a ban was passed in Mississippi, some trans youth reported that their pediatricians stopped seeing them for routine care.
"It has a chilling effect on providers feeling safe providing medically necessary, evidence-based care," Keuroghlian said. "It has a chilling effect on medical trainees and healthcare trainees pursuing much-needed careers in gender-affirming care, and it has a terrorizing effect on trans and gender-diverse youth and their families who are seeking this life-saving care."
Regardless of whether survey respondents practiced in states with bans against gender-affirming care or not, nearly all providers expressed concern that legislation would limit healthcare access for children and worsen mental health for an already vulnerable population. A 2021 Trevor Project survey found that 37% of trans and nonbinary youth experienced physical threats or direct harm because of their gender identity.
"This is a community that already experiences disproportionate harassment, violence and hate crimes, and now there is a specific focus on restricting access to medically necessary care, which is fundamental for people to be able to function and thrive," Keuroghlian said. "It's an especially cruel and inhumane strategy for oppressing an already marginalized and minoritized community."
The gender-affirming care bans pushing some providers to migrate out of states like Texas coincide with a decrease in the number of doctors pursuing the specialty, creating "care deserts." It's estimated that 3.4 million youth live more than 80 miles away from a pediatric endocrinologist, according to Roberts' study. This doesn't only affect youth seeking gender-affirming care, but also children with other endocrine disorders like type 1 diabetes, she added.
As one provider wrote in the study: "As I begin to look for faculty positions, I will not be looking in states that support anti-trans legislation. This ultimately will impact an entire population that needs endocrine care for various reasons, but I cannot work in a state that does not support health equity."