First, Do No Harm
An Arkansas law & the potential derailing of transgender healthcare
by Chael Needle

[Editor’s note: This article, which appears in the May 2021 print issue, came out before President Biden overturned a ban on discrimination against transgender individuals in healthcare in sites that receive federal funding.]

The state of Arkansas excludes individuals from healthcare, openly, directly, legally. With the passage of Act 626, youth of transgender experience under the age of eighteen are banned from gender-affirming healthcare. Healthcare professionals are prohibited from providing “gender transition procedures to any individual under eighteen (18) years of age” nor refer “any individual under eighteen (18) years of age to any healthcare professional for gender transition procedures.” The law also denies public funding and public/private health insurers from supporting gender-affirming care, which includes prescribing puberty-blocking drugs and cross-sex hormones, or performing gender-affirming surgeries. Fifteen other states have similar bills.

The denial of healthcare is focused on children but arguably the law aims to dissaude adult individuals and healthcare providers from even considering gender-affirming surgery: “It is of grave concern to the General Assembly that the medical community is allowing individuals who experience distress at identifying with their biological sex to be subjects of irreversible and drastic nongenital gender reassignment surgery and irreversible, permanently sterilizing genital gender reassignment surgery, despite the lack of studies showing that the benefits of such extreme interventions outweigh the risks; and [t]he risks of gender transition procedures far outweigh any benefit at this stage of clinical study on these procedures.”

This is a blatant denial of scientific evidence. Many studies have shown the exact opposite [e.g., “Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment” by Annelou L.C. de Vries et al in Pediatrics October 2014, 134 (4); and “Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts” by Johanna Olson-Kennedy, MD et al in JAMA Pediatr. 2018;172(5)].

While this issue is not directly related to HIV care, it does speak to the panoply of difficulties faced by people of transgender experience in engaging in healthcare (see, for example, the 2016 survey conducted by the National Center for Transgender Equality, which compiled responses from almost 28,000 participants on a variety of issues, including healthcare). The codification of a healthcare barrier is the complete opposite of “first, do no harm.”

A&U talked to Amida Care President and CEO Doug Wirth about the issue of healthcare access for people of transgender experience.

Chael Needle: Arkansas became the first state to ban gender-affirming care for trans youth under the age of eighteen. In your estimation, does this ban exploit the legal limitation of children to make healthcare decisions about their own health? Do children have greater autonomy in states like New York?
Doug Wirth: This ban absolutely exploits the legal limitation of children to access medically necessary, gender-affirming healthcare. This bigoted law stigmatizes an already-vulnerable population and sends a damaging message to transgender and gender non-conforming youth that they are unworthy of the care they need to live authentically.
In New York, children do indeed have greater autonomy. As of 2020, for example, New York allows trans youth to correct the gender designation on their birth certificates, which updated a previous law that only included those over the age of eighteen. I am proud to say that New York has been a beacon for the LGBTQ community and is a national leader in gender-affirming care and services.

The name of the bill, which then became an act, uses extremely biased language to say the least: Save Adolescents from Experimentation. And its acronym, SAFE, raises the specter of many well-established stereotypes used against people of transgender experience (bathroom bills, for example). How does your organization understand gender-affirming care for clients of transgender experience?
Gender-affirming care is vital and leads to better health outcomes, including fighting the HIV/AIDS epidemic, which disproportionately impacts the transgender community. Amida Care is proud to help our transgender members access the full continuum of transgender health services. Our high-touch model of care successfully engages our members in health services, including HIV prevention and treatment.

Amida Care has more than 750 transgender members who are HIV-negative, and as many as 25% are accessing pre-exposure prophylaxis (PrEP), a powerful HIV prevention tool. We have also had tremendous success helping our members of transgender experience who are living with HIV become virally suppressed or undetectable, meaning that they are unable to sexually transmit HIV to others. Of our more than 1,800 transgender members, over 60% are living with HIV, and 80% of them are undetectable.

Many of the discussions in A&U center around engaging (mostly adult) people living with HIV/AIDS in care and the difficulties for clients to find healthcare spaces that they trust, that affirm their identity, that empower them, and so on. What are the potential effects of actively disengaging children from healthcare?
Transgender youth are already more likely to suffer from anxiety, depression, and suicidal thoughts. It is heartbreaking and alarming to see laws pass that codify discrimination and exacerbate health risks. To add to this problem by barring access to healthcare at an early age is simply unconscionable.

As Amida Care detailed in our report Breaking Barriers to Transgender Health Care, barriers to accessing healthcare and discriminatory laws like this have very real, devastating consequences.

According to recent surveys, 1 in 4 transgender respondents reported having to teach healthcare professionals about transgender care, 28% report having been harassed in a doctor’s office, and nearly 25% avoided seeing a doctor out of fear that they would be mistreated. For communities that are deeply affected by HIV, we need to do more to ensure that all healthcare practitioners, from primary care to hospital staff, are trained and well-equipped to offer culturally competent care.

Briefly, how does Amida Care strive for health equity?
Amida Care strongly advocates to dismantle racism, homophobia, sexism, transphobia, and all forms of discrimination so that people can access the healthcare they need.
We are the largest Medicaid Special Needs Health Plan (SNP) in New York State, and we’re proud to have a long history of helping the transgender community access high-quality, gender-affirming healthcare. The COVID-19 crisis has reaffirmed the urgent need to create a more equitable health care system. We need to break down systemic barriers that keep healthcare out of reach for many in the transgender community, including violence, lack of employment opportunities, housing instability, food insecurity, and discrimination.

We know that services and care are better when we listen first. We work closely with our members and surround them with a dedicated integrated care team of providers, social workers, health navigators, behavioral health specialists and a designated health home. Amida Care also works with community-based organizations to help members access support for housing, employment, and legal issues.

Chael Needle writes the Art & Understanding column for A&U.