Death threats, legal risk and backlogs weigh on clinicians treating trans minors

Dr. Kade Goepferd has received death threats for their work treating transgender youths at Children’s Minnesota Hospital, but Goepferd said the harassment isn’t the most worrying part of the job.

“The waitlist is what keeps me up at night,” said Goepferd, who uses they/them pronouns. “It has grown every year, and it got particularly long after the bans went into effect.”

Goepferd is the medical director of the hospital’s Gender Health Program, the only multispeciality pediatric gender clinic in Minnesota. The program has experienced a 30% increase in calls since surrounding states outlawed gender-affirming care for minors, and the waitlist is now at least a year for new patients, even after Goepferd hired additional staff to help the hundreds of trans youths requesting appointments.

Twenty-six states now have restrictions on transgender health care for minors, according to the LGBTQ think tank Movement Advancement Project. The laws have left those still able to provide this type of care, like Goepferd, struggling to keep up with demand.

NBC News spoke to a dozen clinicians in states where gender-affirming care for minors remains legal, from Connecticut to California, and found all are treating transgender youths fleeing bans. Not only does the surge in out-of-state and newly relocated patients create logistical challenges — from waitlists to insurance denials — it also presents a legal risk for health care professionals. Although some states have enacted protections for gender-affirming care providers, these shield laws remain untested in court, and they have done little to deter anti-trans attacks. Many doctors said they’ve had to take added security measures as transphobic rhetoric has intensified.

“There’s been a growing awareness over the last year that the environment is only getting more and more dangerous for providers,” said Kellan Baker, executive director of the Whitman-Walker Institute, a nonprofit advancing LGBTQ health care.

‘Tenuous protection’

Not all transgender youths seek medical intervention, and while the total number of minors diagnosed with gender dysphoria has increased in recent years, the percentage pursuing transition care has decreased, according to data collected by Reuters and Komodo Health Inc. In a 2022 report, the organizations found around 13% of trans youths sought medical intervention in 2021, down from 17% in 2017. Meanwhile, the number of laws targeting providers has risen rapidly since 2021, when Arkansas became the first state to ban gender-affirming care for minors. Now, more than half of U.S. states have such restrictions in place.

Proponents of these laws say they prevent harmful experimentation on children, who they argue are not mature enough to make life-altering decisions about their bodies. However, the bans contradict the consensus among major medical associations, which recommend the treatment of gender dysphoria before age 18.

Care for young children involves only social changes, such as a new name and pronouns. For some preteens, the next step is puberty blockers, medication that suppresses the development of distressing secondary sex characteristics like facial hair. Once patients reach adolescence, they can start gender-affirming hormone therapy, which allows teens to mature into the gender matching their identity and is the same protocol used with trans adults. Gender-affirming surgery, such as the removal of breast tissue, is rarely performed on minors, but these procedures are also outlawed for youths in dozens of states.

The consequences for violating transgender care bans range from loss of medical license to criminal charges. It is now a felony in six states — Alabama, Idaho, Florida, North Dakota, Oklahoma and South Carolina — to prescribe puberty blockers or hormone therapy to transgender youths, according to KFF, formerly known as the Kaiser Family Foundation. Twenty states impose civil and professional penalties, such as empowering parents to sue or subjecting providers to discipline from the medical board, KFF reports. Those sanctions are paired with an “aiding and abetting” clause in eight states, preventing doctors from even referring families elsewhere for treatment.

Jennifer Pepper, president and CEO of CHOICES Center for Reproductive Health, an LGBTQ and women’s health care organization, said the bans are borrowing tactics from the anti-abortion movement.

“It’s having the same nightmare all over again,” said Pepper, whose Illinois clinic offers gender-affirming hormone therapy to teens 16 and up. “You make it about safety, and you make it about these providers who don’t actually care about patients. And those are all the same words and plays that we saw right after the Roe v. Wade decision.”

Sixteen states have enacted so-called shield laws or executive orders that help gender-affirming care providers practice without repercussions, according to Movement Advancement Project. These policies prohibit information-sharing with prosecutors in states with bans and block the extradition of health care professionals.

Milo Inglehart, a staff attorney at the California-based Transgender Law Center, said the clash between bans and shield laws has created tremendous uncertainty for providers.

“We haven’t seen this much state legal conflict since the Civil War, practically,” Inglehart said.

Inglehart and other advocates fear the shield laws aimed at gender-affirming care providers may not hold up in court. So far, the only test has come from Texas Attorney General Ken Paxton, who demanded the medical records of transgender patients at Seattle Children’s Hospital. The hospital — which falls under Washington’s shield law — filed a lawsuit against Paxton and, as part of a settlement, he dropped the request.

Nonetheless, Kellan Baker said he advises health care professionals not to rely on these policies. Many providers under shield laws agreed, telling NBC News they still feel at risk treating out-of-state patients.

“It’s a tenuous protection,” said Dr. Molly McClain, medical director of the University of New Mexico’s Deseo clinic for transgender youths. “I’m not afraid now, but I think we’re just going to have to see.”

The Supreme Court has agreed to hear its first case on gender-affirming care next term, marking a potential turning point for providers. The court will weigh whether Tennessee’s ban violates the equal protection clause of the 14th Amendment.

In the meantime, the patchwork of state policies makes telehealth especially fraught. Dr. Izzy Lowell, founder and director of the online clinic QueerMed, is based in Georgia but serves transgender teens and adults nationwide. She’s able to avoid the bans by asking patients to travel for their virtual appointments.

“The way the telemedicine law works is that wherever the patient is located at the time of the visit, that state’s laws apply,” Lowell said. “So we have patients drive or fly or whatever from wherever they are over the border into a state without a ban.”

Lowell said she also employs “about a dozen” attorneys to monitor gender-affirming care laws. Last year, she received a demand for patient records from the Texas attorney general, and she later told The Washington Post she would not be complying. She declined to comment on the matter to NBC News.

Telemedicine provider Dr. Crystal Beal said they consider their own practice a form of civil disobedience. Beal, who uses gender-neutral pronouns, is the founder and CEO of QueerDoc, a telehealth clinic treating patients in 10 states, including a few with bans. As a nonbinary femme, Beal said, they feel compelled to defy anti-trans laws.

“I provide care in a different way than my allied colleagues,” Beal added. “I’m worried about my community dying.”

‘A completely clogged system’

More than a third of transgender teens in the U.S. now live in states with bans on trans health care for minors, according to the Movement Advancement Project. These restrictions have driven thousands of young people to seek transition-related care out of state, straining resources at the network of gender clinics still open.

Three-quarters of the providers NBC News interviewed had waitlists of at least three months, with some as long as a year. Dr. Sumanas Jordan, medical director of Northwestern Medicine’s Gender Pathways Program in Chicago, said her clinic is flooded with calls every time a ban passes.

“We actually have a script, because the volume increases so much that we have to have a lot of people help us,” Jordan said, noting that Northwestern’s calendar has remained “constantly full” even as more appointments have been added.

Overcapacity is a common problem for gender-affirming care programs, according to Dr. Johanna Olson-Kennedy, president-elect of the U.S. Professional Association for Transgender Health (USPATH) and medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles.

“Our waitlists get long, we hire a provider, and then our waitlist goes down, and then it goes up again,” Olson-Kennedy said. “But that’s like the L.A. freeways. We’ll never catch up to the amount of traffic.”

Many gender clinics are also experiencing a rise in insurance issues due to the bans. Because Medicaid and some private plans won’t reimburse for out-of-state care, transgender youths often lose insurance coverage if they travel. That forces families to pay hundreds or thousands of dollars out of pocket per dose of puberty blockers or hormone replacement.

McClain said the cost is a major barrier for her out-of-state patients, with around 1 in 5 unable to continue treatment after arriving at her New Mexico clinic.

“Even the ones who are privileged enough to get here aren’t always wealthy enough to be able to afford the medications,” McClain said.

Finding a pharmacist to fill these prescriptions presents another challenge. McClain relies on a pharmacy that ships over state lines but has no backup if it closes.

“I don’t know what we’ll do at that point,” she said.

While telemedicine offers more flexibility, Lowell said her patients in states with bans get pushback from pharmacists “all the time” and have to shop around. Many of them use travel grants from the Campaign for Southern Equality, a nonprofit that helps transgender youths access services in non-ban states.

But even with funding available, the frequent trips required to keep a transgender teen current on medication can put care far out of reach for some families. Unlike with an out-of-state abortion, they need to return for appointments multiple times a year, if not relocate entirely. And moving to a shield-law state such as California typically comes with a high cost of living.

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Melissa Santos, head of pediatric psychology at Connecticut Children’s, is concerned low-income patients will be shut out of care altogether if leaving home becomes their only option. She oversees a research project on transgender youths and has seen firsthand how families are struggling to restart their lives in Connecticut.

“It is going to end up being a completely clogged system where only those with means will ever be able to access it,” Santos said of the overburdened clinics in shield-law states.

Although telemedicine has allowed some gender programs to expand, Lowell warned that it’s inaccessible to most practices. “It’s very, very difficult to get additional state licenses,” she said.

At the same time, the bans are limiting medical school and residency choices for the next generation of gender-affirming care providers. That creates a “vicious cycle,” said USPATH President Dr. Carl Streed, where there aren’t enough new doctors to handle the influx of patients in shield-law states.

“When you shut down locations where you provide this care, you’re losing opportunities for people to be trained there as well,” Streed said. “Therefore, we lose the opportunity to have more folks be able to provide this care.”

‘Simmering in the background’

The spread of health care restrictions has also made providers a political target, with some saying they’ve been harassed relentlessly by the far right. Olson-Kennedy said the anti-trans attacks have come as a shock to most medical institutions.

“These are probably not the things that pediatricians and pediatric hospitals are used to,” she said. “But these are things that trans people are used to.”

The majority of gender-affirming care providers NBC News interviewed had received threats, ranging from angry calls and emails to arson. Even a doctor in liberal San Francisco said he had someone vow to kill him and his dog.

“It’s always kind of simmering in the background,” Dr. Kade Goepferd said of the harassment directed at their field. “It strengthens my resolve that this is really important work.”

Last year, an arsonist destroyed Lowell’s practice in Georgia, leaving behind graffiti that made their intentions clear. The FBI is now investigating the incident as a hate crime, according to Lowell.

“Mine was the only office that was burnt, and it was burnt completely,” Lowell said. “To the point where they had to ask, ‘Was there a computer on the desk?’”

This climate of fear has led many clinics to avoid publicity and increase security measures for their staff. Some practices have removed contact information from their websites or considered erasing their online presence entirely.

Several of the largest pediatric gender programs in the country, including Seattle Children’s, Children’s Hospital Colorado in Denver and Lurie Children’s Hospital of Chicago, declined interviews with NBC News.

Dr. Joshua Safer, director of Mount Sinai’s Center for Transgender Medicine and Surgery in New York, said he had to stop sharing his team’s street address online due to threats. He decided to risk keeping the rest of the website up to reach teens in states with gender-affirming care bans.

“If you’ve got some kid,” Safer said, “and their only access to information is in their bedroom on their computer, I wanted them to find Mount Sinai.”

Some transgender health care providers under shield laws said they feel a kind of survivor’s guilt, a sense that they could be doing more to help patients and colleagues in states with bans. Olson-Kennedy described it as a “moral wound” for the doctors still able to practice.

Goepferd said the anti-trans messaging weighs on them, despite the joy and purpose they’ve found in their work.

“It’s emotionally exhausting to be targeted,” Goepferd said. “It’s also really sad and painful to watch the patients and families that you care for be targeted.

“I’m glad that I can offer them care, but I can’t take that away from them.”

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This article was originally published on NBCNews.com