Abstract
Objectives:
This qualitative study explored the beliefs and values influencing healthcare providers’ delivery of gender-affirming care (GAC) to transgender and gender-diverse (TGD) youth amidst current social and political dynamics.
Methods:
The study PI conducted 43 semi-structured interviews with providers across states with varying GAC legislation. Responses from 41 providers were analyzed in this paper. A thematic approach to data analysis was employed using qualitative coding.
Results:
Key themes emerged: criteria for treatment, ethical and moral considerations, and professional and personal responsibility. Providers widely endorsed GAC as evidence-based and essential for alleviating distress and promoting autonomy. They emphasized the importance of respecting patients’ gender identities and viewing GAC as life-saving.
Conclusion:
Despite legislative challenges, the study highlights a strong consensus among providers on the medical necessity of GAC for TGD youth.
Keywords
Introduction
The social and legal landscape for gender-affirming care (GAC) in the United States is rapidly changing, which means that providers who treat transgender and gender-diverse (TGD) youth may have to modify their clinical practices to comply with new laws. These laws sometimes contradict their medical judgment, particularly when such legislation restricts evidence-based practices deemed necessary for their patients’ health and well-being.1,2 Moreover, changing legislative, social, and political dynamics likely affect clinicians’ beliefs and values about the provision of GAC. 3 Some providers may experience moral distress or, alternatively, view advocacy as part of their responsibility to provide care for their patients.4,5 The spread of state legislative bans, protests, threats against clinics and providers, and limits on care likely impact how pediatricians think about providing GAC—even in states without such laws. 6 These social dynamics may influence how pediatricians think about and discuss a sensitive issue like trans and nonbinary gender identities with patients, patients’ families, and professional colleagues.
This qualitative study explored provider beliefs and values informing provision of GAC amid today’s shifting social and political environment. The beliefs and values that inform providers’ provision of GAC are inseparable from TGD youth health outcomes. 7 Providers’ beliefs and values inform their medical judgment and thus impact how they provide care for TGD youth. Relatedly, the health outcomes in TGD youth receiving GAC inform providers’ beliefs and values about the medical necessity of GAC.
The current literature on values and beliefs of providers, specifically the Cass Review and responses, predominantly articulates those of providers who oppose GAC. 8 While there are many critiques of this research, the input from providers who treat TGD youth is limited in this work.9 -11 Threats to providers’ safety and the accompanying attention drawn to their patients often prevent clinicians from speaking out about their individual beliefs and values. 12 Safety concerns make necessary studies that can protect provider anonymity. This qualitative study sought to amplify the voices of those doing this work while also providing a national perspective on the beliefs and values of those currently providing GAC.
Methods
Study Population
The study included 43 providers (MD, DO, NP, and PA) from 24 states with varying legislation (Table 1). Inclusion criteria consisted of (1) being a medical provider; (2) practicing in the United States; and (3) treating TGD youth. Both specialists and generalists were included, such as those in adolescent medicine, pediatric endocrinology, family medicine, and general pediatrics. Participants practice in various settings, including family practices, community clinics, and those affiliated with gender clinics. We aimed to recruit a sample that was reflective rather than representative, capturing diversity in geographic location, practice setting, career stage, and provider identities.
State Distribution by Legislation Status.
Instrument Development
We utilized a phenomenological approach to conceptualizing and conducting this study. The interview guide for this study was developed through a multi-step process to ensure it comprehensively addressed the research project’s objectives. The development of the guide began with an extensive review of existing literature on GAC, provider beliefs, and legislative impacts. This review informed the initial set of questions, ensuring alignment with prior research insights and identification of gaps requiring further exploration.
Subsequent iterations of the interview guide were made based on consultations with subject matter experts, including providers who treat TGD youth and qualitative health researchers. Their feedback was instrumental in refining the phrasing and scope of questions to ensure clarity, relevance, and sensitivity to the diverse practices and perspectives of participants. The iterative process prioritized creating a guide that allowed providers to share their experiences and insights without presupposing uniformity in their practices or beliefs. Special attention was given to streamlining the guide to reduce interview length and cognitive load, thereby lowering participant burden without compromising the depth or breadth of data collection. The instrument ultimately consisted of 20 open-ended questions designed to explore providers’ beliefs, values, and experiences regarding the provision of GAC to TGD youth amidst shifting social and political climates.
Participant Recruitment
The recruitment strategy began with 5 local contacts, each responsible for recruiting 8 to 10 participants, complemented by snowball sampling. States were selected based on differing legislation regarding GAC for minors: Ohio, New York, Massachusetts, Arkansas, and Florida. These states were selected to capture diverse legislative contexts; they represented a mix of states with legislative bans, shield laws, and no legislation (neither ban nor shield law). Shield laws preserve access to GAC by providing legal protections for providers and families from punitive action by other states with legislative bans. These laws vary in specifics from state to state. 13 Ohio and New York experienced legislative changes shortly before the study, with Ohio implementing a ban and New York passing a shield law. Massachusetts was chosen due to its comprehensive shield law, while Arkansas and Florida both saw bans overturned by federal judges before the study commenced. Even with the legislative changes during the time from study design to study implementation, these states reflected the different legislative possibilities for GAC bans and protections. Because GAC is a highly politicized and sensitive issue, the reasoning behind this approach was that providers would be more likely to enroll in a study if they were referred by someone they know and trust.
Despite some success, this approach required adjustments. The recruitment ultimately involved a mix of local contacts, snowball sampling, and a listserv dedicated to trans health. The listserv was instrumental in reaching underrepresented areas and demographics. Members of the listserv additionally shared with outside contacts and referred participants. Snowball sampling proved most effective, as participants felt more comfortable being referred by trusted colleagues amid the politically sensitive nature of the study. 14
Data Collection
The PI conducted 43 semi-structured interviews between May and July 2024. A total of 41 providers explicitly responded to the questions about beliefs and values analyzed in this paper. The open-ended questions allowed participants to discuss perspectives and challenges in providing GAC amidst shifting political and social climates. Interviews continued until data saturation was achieved, providing a comprehensive view of provider experiences. To understand current practices and experiences, it was essential to hear from a range of voices responding to the same questions. The guide included questions such as: (1) What is your position on the provision of GAC to TGD youth? (2) Can you describe the values and beliefs that support that position?
Interviews were conducted via Zoom, recorded with options for participants to turn off cameras. Given the vulnerable nature of the topic and the current political and legal climate, an NIH Certificate of Confidentiality was used to protect participants, with participant confidentiality concerns discussed during the verbal consent process. 15
Data Analysis
All interviews were transcribed verbatim prior to coding and analysis to ensure accuracy. For data analysis, a thematic approach was employed using ATLAS.ti qualitative coding software (version 25.0.0.32864, ATLAS.ti Scientific Software Development GmbH). An inductive coding strategy was utilized to develop a codebook, which was applied by 3 experienced coders. The coders worked collaboratively to reach consensus and identify common themes across the interview transcripts.
Results
When exploring the beliefs and values guiding healthcare providers’ positions on GAC, 3 primary themes (Table 2) emerged: criteria for treatment, ethical and moral considerations, and professional and personal responsibility. Additional secondary themes discovered—holistic approach to care, advocacy and education, type of treatment, challenges and barriers, impact of states laws and legislation, personal and professional frustration, and disinformation—are included in Table 2.
Qualitative Analysis Themes.
We also analyzed the emergent themes in the context of gender-affirming care legislation (ban on GAC, shield law, or no legislation), allowing us to see how providers from different legislative contexts expressed their beliefs and values (Table 3). Providers in states with bans of GAC provision stressed the importance of GAG as evidence-based medicine, diagnosis and consistency of gender dysphoria, and the role of a provider’s medical judgment. Those in states with shield laws likewise emphasized evidence-based medicine and medical judgment, but they additionally stressed the importance of patient rights and autonomy. Providers in states without legislation (neither a shield law nor a ban) expressed patient rights and autonomy and the role of healthcare providers as central themes.
Key Theme Frequencies Categorized by Legislation Context.
Criteria for Treatment
The most prevalent theme among the 41 providers whose responses are included in this study was criteria for treatment, emphasizing GAC is evidence-based medicine that reduces suffering in TGD youth who meet the criteria for treatment. Providers’ endorsement of GAC as evidence-based reflects a broad consensus within the medical community. They asserted this care aligns with guidelines from the World Professional Association for Transgender Health (WPATH) and support from leading medical organizations such as the American Medical Association and the American Academy of Pediatrics.16
-18 Providers practicing in states with bans on GAC provision were most likely to emphasize clinical rigor, with 27 responses highlighting evidence-based medicine compared to 15 in shield law states and 7 in states with no legislation. Similarly, the importance of consistent diagnosis and addressing patient distress and suffering was most often expressed by providers in states with bans. One provider explained:
If the patient meets the criteria, including the really critical part is if they’re having distress and suffering, and if it’s causing them pain, then it’s very important to treat it. . .Not everybody wants medical treatment with hormone therapy. Most people do, not everybody, not everyone wants surgery, but if someone is suffering and having pain from lack of medical treatment, then it’s absolutely appropriate—in fact, medically necessary—to treat them.
Another clinician echoed these sentiments, but added that evidence points to success in earlier interventions if a patient meets all treatment criteria:
I’m in support of providing GAC to anybody of any age that they qualify for. There are some medical treatments that are too complicated to do for a minor, or they might be too risky to do in a minor, and those are sometimes reserved for minors that have gone through intense interview process, or young adults when they’re able to go through that process. There’s evidence to show that early intervention in appropriate environment, within the appropriate environment does produce better outcomes. So, it’s best, what we know is medical-community-wise, it’s better to intervene as early as somebody shows signs of dysphoria with GAC to prevent deterioration of mental health and prevent future comorbidities that could be long lasting and devastating for the rest of their life.
Starting GAC early, according to this provider not only helps to alleviate current distress and suffering, but also prevents youth from worse mental and physical health outcomes that can occur in when TGD individuals live with ongoing gender dysphoria.
Ethical and Moral Considerations
The central theme of personal autonomy and respect for patients’ rights emerged strongly from providers’ accounts. They consistently emphasized the importance of respecting individuals’ rights to make informed decisions about their own treatment, framing GAC as not merely beneficial but essential for achieving optimal health outcomes. This principle was most frequently highlighted in states with shield law protections (11 responses), followed by states with no legislation (10), and was less prominent in state with bans (5). One participant stated:
I believe in universal healthcare and that everyone has the right to what they need to achieve their optimal health outcomes. All of us have different health potential, but we should all have access to the care we need to achieve our best outcomes, which is kind of the definition of health equity. So, I believe in equitable healthcare for everyone, including TGD young people. And they have specific healthcare needs that are different from kids who are not TGD, and they should be able to access that care.
Relatedly, providers stressed GAC is life-saving care that reduces risk of suicide, improves mental health, and allows youth to fully participate in their lives. This belief was particularly emphasized in restrictive states, where 11 providers highlighted GAC as life-saving compared to 6 in shield law states and 5 in states with no legislation. A provider said of the GAC bans:
It’s like all of a sudden, the government outlaws chemotherapy. And we are – we can’t refer to hematologists, oncologists; we can’t provide life-saving treatment because the government is saying we can’t. It’s like that.
Additionally, providers in shield law states often noted that “children know their gender” (7 responses). This early recognition supports the importance of timely and appropriate medical intervention to support mental health and overall well-being. One provider reflected on their interactions with patients:
Almost each and every time, I’m like, “When was it that you first recognized that I am trans?” And almost always, they say since childhood or since adolescence, no matter how old they are, they are like, “Well, I’ve always known.” Can you imagine always knowing, but then fighting this tide, and then being so courageous? It’s courage that is beyond, right? I mean, we’re all scared of this or scared of that, and we have anxieties, but can you imagine saying, “All right, I’m going to live my life so authentically and so genuinely, and it starts now.”
Providers additionally noted the importance of recognizing gender as a spectrum and paying attention to the needs of individual patients (6 in restricted states, 4 and 3 in shield law states and states with no legislation, respectively). A participant shared a patient story highlighting the fluidity of gender and life-saving importance of access to GAC:
They were talking about how even though they stopped the GAC at one point, that was still part of their transition and that they recognize that that probably saved them from suicide attempts or self-harm at the time, because gender is a fluid thing and gender doesn’t have to be one or the other, and it can change as time goes on. And I think we should just allow children and teenagers the same right to make those changes as anybody else.
Professional and Personal Responsibility
Finally, many providers viewed offering GAC as a responsibility integral to their role as healthcare providers and part of their duty to patients. They frequently discussed GAC as being like all other forms of treatment in which they offer options in an objective manner and ultimately leave the decision up to patients. This perspective was most prevalent among providers practicing in states with shield law protections, where 8 responses emphasized the importance of medical judgment in decision-making compared to 6 in states with bans. One provider reflected upon a formative experience:
I remember very early on giving a talk to some local psychiatrists, child and adolescent psychiatrists and having one of the psychiatrists ask me if I approved of what my patients were doing. And I was really taken aback because I don’t even have that frame. I mean, I guess I approve, but that’s really not the lens through which I think about this. My approval or disapproval has no bearing on their lived experience.
Participants also described the provision of GAC as part of their medical judgment. Criteria for treatment, ethical considerations, and professional responsibility all inform how providers make decisions with their patients.
Along with their professional obligation to their patients, many clinicians stressed a personal responsibility that comes with treating a vulnerable patient population. A participant described their experience:
But I’ve grown more personally, and [I’m] passionate and emotional about [GAC] as I’ve met with transgender teenagers in my community through some advocacy work we’ve done together who’ve shared their mental health challenges. They’ve shared about their suicidality, a lot of which has just been rooted in not being accepted and not feeling like themselves in their own body. And so, I think I’ve grown more impassioned about the need for everyone to be able to appreciate their experiences and to offer this care because I know that it does save lives. And every time we lose a student who’s trans in our community to suicide, we lost one a couple of weeks ago, I wonder what more could be done. And I know clinicians are just one factor in their social network but can be quite influential.
Discussion
These themes illustrate the complex interplay of evidence-based practice, ethical principles, and professional duty, all of which inform providers’ perspectives on GAC. The study highlights the profound ethical, moral, and professional considerations that underpin the delivery of GAC for TGD youth. 19 The perspectives of healthcare providers, as revealed in the study, align with a substantial body of literature emphasizing the life-saving and essential nature of GAC.20,21 Research further supports the efficacy of GAC, demonstrating reductions in depression and suicidality among TGD youth who receive appropriate care. 22 Providers’ analogies likening legislative bans on GAC to banning critical treatments such as chemotherapy demonstrate the gravity with which they view these interventions.
The participants in this study asserted youth’s right to access care that improves their health. Many described cases in which youth clearly articulated their gender and gender dysphoria was consistent, insistent, and persistent. Providers acknowledged the necessity of listening to youth’s individual understandings of their gender, knowing they may or may not line up with binary gender expressions. The recognition of gender as a spectrum, as highlighted by providers, aligns with contemporary understandings of gender identity and expression.23,24 In this context, providers in states with no legislation or shield law protections most frequently emphasized that gender is a spectrum, which further supports the view that timely and appropriate medical interventions can foster positive health outcomes.
Providers’ sense of professional responsibility toward TGD youth was a recurring theme, as a provider and an ally. This responsibility is viewed not only as a medical duty, but also as a form of resistance against restrictive and politically-driven policies. 25 The study shows the close ties between medical judgment and ethical beliefs, with providers in states with GAC bans emphasizing evidence-based practice and the need to treat distress and suffering, while those in shield law states focused on autonomy and patients’ rights. As observed, providers practicing in states with bans on GAC often felt a heightened sense of urgency in advocating for their patients, emphasizing that their medical judgment was critical in ensuring access to care despite external pressures. It is apparent that in restrictive environments, providers often see their role not only as delivering medical care but also as advocating for patient rights and resisting policies that compromise patient well-being. The commitment of providers to deliver compassionate, evidence-based care, even in the face of restrictive legislation, underscores the importance of their advocacy efforts in maintaining access to GAC. 26
Limitations
There are limitations to this study, including the possibility of investigator bias during the interview and analysis process. Another possible limitation is that a large percentage of the providers interviewed identify as cisgender women. While this does seem reflective of the demographics of GAC providers, it could bias the results.
Conclusions
This study reinforces the critical role of GAC in supporting the health and well-being of TGD youth. Moreover, many of the beliefs and values articulated by providers directly counter the claims of the Cass Review, arguing GAC is evidence-based medicine and children and adolescents know their gender.27,28 The American Academy of Pediatrics stresses that restrictive policies not only threaten access to essential care but may also exacerbate existing health disparities.18,29 Future policy efforts should prioritize the values of providers and seek to protect access to GAC, ensuring political and legal barriers do not compromise the well-being of TGD youth. The findings of this study, supported by extensive literature, demonstrate the ethical imperative to provide GAC to TGD youth who meet the treatment criteria. 30
Footnotes
Acknowledgements
The authors thank Xan Nowakowski for their thoughtful feedback on this manuscript.
Author Contributions
Ahona Shirin: software, formal analysis, data curation, writing—original draft, and project administration. Maya Daniello: validation and formal analysis. Laura Stamm: conceptualization, methodology, investigation, formal analysis, writing—review & editing, and supervision.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Robert Wood Johnson Foundation. This content is solely the responsibility of the authors and does not necessarily represent the official views of the Robert Wood Johnson Foundation.
Grant number: 81517
Ethical Approval
Our study was approved by the University of Rochester Institutional Review Board (STUDY00008344). All participants provided verbal consent prior to participation in the study.
