In January, the Ohio Senate successfully voted to override Gov. Mike DeWine’s veto of a bill that, pending litigation, will take effect in April and ban gender-affirming care for transgender and gender-nonconforming minors in Ohio. House Bill 68 also requires physicians to report certain medical information about their trans patients to the Ohio Department of Health, which physicians have called “invasive” and “unnecessary.”

The Ohio bill is but one thread in a tapestry of bills covering the country – the ACLU is currently tracking 425 bills it designates as anti-LGBTQ – as states legislate transgender rights this election year. Just on Wednesday, the West Virginia House voted to move a bill forward that includes language defining “man” and “woman,” and codifies same-sex environments such as locker rooms as non-discriminatory.

Doctors and advocates are calling many such bans on the transgender community unconstitutional – court cases abound – and they note such legislation will increase suicide rates in a population that already struggles with higher-than-average rates of mental illness.

“Among youth who desire gender-affirming care, they report dramatically better health care outcomes,” said Harry Barbee, a social scientist at Johns Hopkins Bloomberg School of Public Health specializing in LGBTQ research. “When you pair that with the fact that trans youth already have a high risk of suicidality, that’s a really important potential intervention.”

Gender-affirming care refers to any care a trans or gender-diverse person might receive to help them feel more comfortable in their bodies. Care can include mental health counseling; hormone replacement therapy, such as with estradiol or testosterone, and puberty blockers; laser hair removal; and surgeries such as chest feminization or masculinization.

Estimates of the population in the U.S. vary, though a widely cited 2022 Pew Research poll found that it encompasses about 5.1% of adults ages 18 to 30; a survey from UCLA School of Law’s Williams Institute reported 1.4% in the 13-17 age range the same year.

Even in non-election years, gender-affirming care has been a topic of concern among certain legislators. Ohio’s HB 68 is not the first law to ban access for minors — 22 other states restrict this type of care in some way, according to September 2023 data from the Human Rights Campaign.

As parents of transgender children prepare for an uncertain future, Pittsburgh clinics expect an increase in patients traveling from Ohio for care, similar to the influx of people seeking abortions from the state following the collapse of Roe V. Wade.

Pennsylvania currently does not restrict gender-affirming care. The City Council underscored this in September when it voted to deem Pittsburgh a “sanctuary city” for transgender health care, which means those out of state may see it as a refuge.

David West, the president of PFLAG Pittsburgh, a nonprofit that supports LGBTQ people and their loved ones, said they have already seen an uptick in West Virginians seeking their services and are expecting the same from Ohio shortly. West Virginia banned most gender-affirming care for minors in January.

“We are preparing for people to cross the border for help,” he said.

A middle school teacher with a 20-year-old trans son, West said the ban was “a knee-jerk reaction to a threat that doesn’t exist.”

The main argument among opponents revolves around the notion of protecting children, with claims that gender-affirming care is akin to mutilation, or that children are being coerced into it. The Ohio bill, for instance, states that “the risks of gender transition services far outweigh any benefit at this stage of clinical study on these services.”

The medical community at large disagrees with such bans, with every major medical institution, including the American Psychiatric Association, the American Medical Association and the American Academy of Pediatrics, supporting gender-affirming care.

Rates of mental illness and suicide attempts remain high in the LGBTQ population: More than half of all trans and nonbinary people ages 13 to 24 seriously considered suicide in the past year, per the 2023 U.S. National Survey on the Mental Health of Young People, run by The Trevor Project, an LGBTQ-supportive nonprofit and research group.

Research shows these rates increase when legislation is introduced that aims to restrict their rights, and when they struggle to access care. That can change when care is available.

One 2022 study published in JAMA Network Open found that a year after trans and nonbinary youth received gender-affirming care, their risk of suicidality went down by 73%.

“This isn’t a new and untested method of treatment,” said Mary-Beth Wyko, a spokesperson for Allies for Health + Wellbeing, an inclusive clinic in East Liberty. “It’s been around for a long time.”

Despite that, experts say gross misconceptions abound regarding what gender-affirming care is and the benefit it holds for trans people.

“There’s a misconception that there’s some type of harm being done to the patient or that it may be unsafe,” said Marvin McGowan, a physician who offers gender-affirming care at Central Outreach Wellness Center’s North Shore location in Pittsburgh. “I’ve overseen thousands upon thousands of patients receiving gender-affirming therapy and, in six years, I’ve never seen an adverse effect.”

Physician Marvin McGowan provides gender-affirming care at Central Outreach Wellness Center on the North Shore.Physician Marvin McGowan provides gender-affirming care at Central Outreach Wellness Center on the North Shore.(John Colombo/For the Post-Gazette)

Across the board, an adolescent who wants to receive gender-affirming care — if a clinic near them offers it — requires the support of a medical team, which includes at least a primary care physician and a mental health specialist, in addition to parental involvement.

MetroHealth Pride Clinic in Cleveland also requires patients to see an endocrinologist, who will run tests to catch hormone imbalances and gauge where the child is in their development.

“What the kid wants is considered, but it’s about what is medically and psychologically advised,” said Ginger Marshall, administrative coordinator of public health programs for the MetroHealth Pride Network. “It always requires parental consent, and any treatment is based on physical or lab-documented changes. … This is not something we hurry through.”

While doctors may ultimately decide that puberty blockers or mental health counseling could benefit a trans kid, surgeries are not recommended for minors, despite proliferating misinformation that they are.

“I don’t know a single legitimate surgeon who would do a genital surgery on a child,” said Charlie Borowicz, transgender health program manager for Allegheny Health Network’s Center for Inclusion Health.

Joy Ellison, a transgender historian at the University of Rhode Island, concurred: “Surgery for minors is not something that any doctor recommends, and it is not something that happens in Ohio to my understanding.”

There’s also evidence that when this population has access to gender-affirming care, they’re more likely to visit the doctor for other reasons, too. A recent study published in the American Journal of Preventive Medicine, with Harry Barbee as an author, showed that when queer people have access to gender-affirming care, they engage more in preventive care, such as cancer screenings and flu shots.

“There’s a misconception that trans people can’t self-determine what is best for their body,” said Borowicz, who is trans and nonbinary. “This extends to a larger conversation that we do not trust people to make decisions about their bodily autonomy, and there’s a concept that autonomy should not apply to youth. There are more safeguards in place than people realize.”

The prime sponsor of the Ohio bill, House Rep. Gary Click, a Republican, said in a virtual meeting on the social platform X that Planned Parenthood clinics “pass out hormones like candy.”

Every person interviewed for this story disputed the claim that hormone therapy is easily accessible. Only 11% of transgender and nonbinary youth ages 13 to 24 reported being on hormones; further, just 2% took puberty blockers, per the 2023 Trevor Project Survey.

“There are a lot of unnecessary regulations, and it makes it very difficult as a parent to feel that your child is safe,” said Adarsh Krishen, the chief medical officer of Planned Parenthood of Greater Ohio. “There’s a significant risk of bullying, suicide and other stress-related mental health issues as a result of not being able to get care they deserve. It makes me very concerned that those things will continue to worsen for those patients.”

Planned Parenthood of Greater Ohio offers gender-affirming care such as hormone therapy to those over the age of 18.

“The impact is going to be very, very devastating for many young people,” said Ellison, who is trans and nonbinary. “What is happening to us should alarm everyone. This is a matter of life and death.”

ACLU Ohio is preparing a lawsuit to fight the ban, aiming to file a preliminary injunction that would halt the law before it goes into effect. Freda Levenson, ACLU Ohio’s legal director, declined to disclose what group specifically the litigation would target in Ohio, but said the ACLU’s argument hinges on upholding constitutional rights.

“It’s a violation of the Ohio constitution for the government to step in and discriminate on this group of people,” she said. “This is well-established health care. This isn’t an experiment.”

That rhetoric has dealt a blow to the mental health of queer people — even when it doesn’t lead directly to active legislation.

“Youth are being sent the message that their deepest understanding of themselves is not true,” said Ellison.

Marshall of MetroHealth Pride Clinic, a trans woman, spoke of how it’s impacted her own mental health.

“I feel like most of the state legislature is targeting me, and trying to destroy my life,” she said. “That raises a stress level.”

One argument against Ohio’s ban is that hormone therapy is not prescribed only to trans and gender-diverse people. Medications such as estradiol are also given to reduce symptoms of menopause and to help treat certain cancers, including breast and prostate, though sending reports about hormone prescribing to the Ohio Department of Health will not be required for these patients.

“If we’re not regulating hormones for cis(gender) people, why are we doing it for trans people?” said Mimi Rivard, a nurse practitioner at Central Outreach Wellness Center in Columbus, who has worked with the trans population for 20 years. “This is identity-based discrimination.”

Providers are still waiting on details about some aspects of the ban. As it stands, the law includes a grandfather clause for patients already receiving gender-affirming care. Those patients can maintain treatment, but it’s still unclear what might happen if they change doctors or require other types of gender-affirming care.

“Right now, we’re kind of in a waiting period,” said Marshall.

There have already been reports of families planning to leave Ohio completely because of new restrictive legislation. Krishen, of Planned Parenthood of Greater Ohio, said the team was planning to hire a new provider who has a nonbinary child, but they’ve since left the state.

“I do think the ban will cause some families to relocate entirely, which is really sad,” said Lizzie Bjork, education and advocacy coordinator of the LGBT Community Center of Greater Cleveland, an LGBTQ support organization that offers primary care through MetroHealth. “I certainly wouldn’t be surprised if demand increased in Pittsburgh,” she said.

Local clinics Central Outreach and Allies for Health + Wellbeing are prepared to see at least some uptick, but aren’t necessarily expecting a deluge. Even if that does occur, McGowan, of Central Outreach, said they have the capacity to handle it: “We’re always ready.”

McGowan, who is also queer, said he has seen more medical students interested in LGBTQ health care than in his earlier decades as a physician. But there’s more opportunity for education about gender-affirming therapy and treating LGBTQ patients, he said, especially for doctors-to-be.

“These young (trans) people understand what they want and who they are,” he said. “What’s happening now is politics.”

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