Restrictions on Transgender Health Care Lead to Increased Travel Time to Clinics

Luca Borah, BA, MD/MPH Student

Credit: LinkedIn

Legislation and policies restricting access to health care for transgender youths have been implemented in 20 US states since May 2023. Luca Borah, BA, University of Michigan Medical School, and investigators authored a research letter exploring the impact of these restrictions on the geographic accessibility of gender-affirming care for transgender youths and their families.¹

The study from the University of Michigan, revealed more than 100 bills related to restricting health care for transgender youths were under consideration in various states. This situation has raised concerns among experts, as access to appropriate medical and social services has been associated with improved mental health outcomes and reduced suicidality among transgender youths.²

The research aimed to assess the effects of these state restrictions on geographic access to gender-affirming care. Investigators identified clinics offering medical gender-affirming care, including puberty-suppressing medications and hormones, for patients under 18 years old in the contiguous 48 states and Washington, DC. The study excluded clinics that solely provided gender-affirming surgery.¹

The presence of enacted legislation, executive actions, funding provisions, or other policies that limited access to puberty-suppressing medications and hormones for patients under 18 years of age were used to define "restriction states." A total of 70 out of 271 gender clinics were considered inactive under these restrictions in 20 states.

Estimating Changes in Geographic Access

The study calculated drive times from the US Census Bureau population-weighted county centroids to the nearest gender clinic under optimal conditions without traffic. A repeated cross-sectional analysis compared drive times before and after state restrictions, taking into account the clinics' active status.

Data from the American Community Survey were used to weigh counties by the population of youths aged 10 to 17 years to determine state-specific geographic access.

The findings revealed significant changes in geographic access and drive times to gender clinics following the implementation of state restrictions. Prior to restrictions, the national median drive time to the nearest clinic was 0.51 hours. However, investigators found under the restrictions, this increased to 0.99 hours, highlighting a substantial difference.

The team noted that before the restrictions, an estimated 27.2% of US youths aged 10 to 17 years lived more than 1 hour away from a gender clinic. After the restrictions, this number almost doubled to 50%, indicating that half of all youths in this age group faced increased travel times to access essential gender-affirming care.

Concerns for Mental Health and Access to Care

The study stated concerns about the potential consequences of these restrictions on the mental health and well-being of transgender youths. It remains unknown whether existing clinics in states without restrictions can handle the increased need from out-of-state patients, particularly with over a quarter of gender clinics located in states with restrictions.

Investigators also pointed out that further legislative advancements in certain states, such as Louisiana and Ohio, could exacerbate geographic barriers, as these states are the closest options for neighboring states with restrictions.

Study Limitations and Implications

The research acknowledged certain limitations, including the use of county-level estimates for all youths rather than transgender-specific populations. The study also acknowledged the inability to identify non-advertising clinicians and all clinics operating before the restrictions.

In addition, factors such as familial support, insurance coverage, financial resources, and discrimination were not considered, which could add further complexities to accessing care for transgender youths, according to the letter.

“Access to developmentally appropriate medical and social services for transgender youths is associated with mental health benefits and decreased suicidality,” investigators wrote. “As more states restrict evidence-based gender-affirming care, the distances youths and their families will need to travel are unknown.”

References:

1. Borah L, Zebib L, Sanders HM, Lane M, Stroumsa D, Chung KC. State Restrictions and Geographic Access to Gender-Affirming Care for Transgender Youth. JAMA. 2023;330(4):375–378. doi:10.1001/jama.2023.11299
2. Grossi G. Suicide Risk Reduces 73% in Transgender, Nonbinary Youths with Gender-Affirming Care. HCPLive. March 8, 2022. https://www.hcplive.com/view/suicide-risk-reduces-73-transgender-nonbinary-youths-gender-affirming-care