The Far-Reaching Impact of Anti-LGBTQ+ Legislation

Awareness of transgender health has never been higher. With an estimated 1 in 50 people worldwide identifying as trans, nonbinary, or gender-fluid—and numbers rising—it’s important to understand the intersection of minority gender identities with healthcare access and delivery. But the issue goes beyond standards of care. 

“Although pathologists and laboratorians may not contribute to a transgender patient’s in-person healthcare experience, we can still have a dramatic impact on their overall experiences and outcomes."

The dramatic rise in legislation that restricts the provision of gender-affirming treatment, and the safety of gender and sexual minorities more broadly, is causing scientific and medical professionals to reconsider where they’re willing to live and work. Many providers have expressed concern for their patients or anxiety over their own careers; some are torn between providing gender-affirming care and adhering to new laws, whereas others fear being targeted for their work or advocacy. Those who are at risk themselves or have vulnerable family members are feeling pressure to relocate. While such concerns are understandable, their effects may threaten healthcare access, equity, and advancement for all patients.

What laboratorians need to know about trans care

“Although pathologists and laboratorians may not contribute to a transgender patient’s in-person healthcare experience, we can still have a dramatic impact on their overall experiences and outcomes,” says Timothy Craig Allen, chair of pathology at Oakland University William Beaumont School of Medicine and chief of the pathology service line at Corewell Health East. 

He acknowledges that not all clinical laboratory professionals will have the same knowledge of trans health care, but sees this as an opportunity to grow: “At a minimum, we should all keep in mind the laboratory basics regarding our transgender patients—for example, understanding that hormone testing may involve transgender-appropriate reference ranges and using preferred pronouns in the electronic medical record.”

Reference intervals are a particularly tricky area because, in many cases, neither of the sex-specific ranges is appropriate for a trans patient. Current solutions to this problem include selecting the most appropriate reference interval for each individual test or reporting tests alongside both male and female intervals; however, calls for reference ranges specific to trans and nonbinary individuals are increasing and several such ranges have already been established.

With gender-affirming care legislation rapidly changing around the world, it can be difficult to keep up. 

Allen recommends having an awareness of the basics and any recent or upcoming changes, but leaving the details to the lawyers. “Laboratorians should have a reasonable understanding of trans healthcare legislation and know when to reach out to experts for assistance in interpreting laws and regulations,” he says. 

In particular, he emphasizes the need to understand the legal implications of providing transgender healthcare, which vary between states and countries. “In the last few years, almost half of US states have enacted bans on gender-affirming care for children and several have enacted similar bans for adults. Some expect more states to ban adult care.” 

In states with prohibitive legislation, the risks extend not only to trans individuals, but also to their healthcare providers. “Some proposed bills would allow for civil liability, the suspension or revocation of medical licenses, or even felony criminal penalties for assisting in gender-affirming health care. Laboratorians and pathologists should have an understanding, with the guidance of legal experts where necessary, of the specific laws and regulations surrounding the provision of trans health care where they are located.”

The living and working landscape

One of the dangers of restrictive healthcare legislation—whether it’s with respect to abortion care, trans care, or other concerns—is that it drives providers away from the areas where they’re needed most. These changes don’t just affect trans health care; they reduce access to quality care for every person in those areas.

“If laboratorians, pathologists, and other healthcare professionals move to states whose laws favor their own views on trans health care, it is possible that some states would lose healthcare professionals. Health care equity would be reduced in those states and the decline in overall health care would affect all patients,” says Allen. Research supports his claims; not only do anti-LGBTQ+ laws reduce health equity and the number of doctors available, they also have a significant economic impact.

The cracks are already beginning to show in states that have introduced more laws limiting the rights and healthcare access of gender and sexual minorities. Doctors and scientists are leaving areas that have brought in new restrictions and avoiding jobs in states they perceive as hostile. Providers involved in pediatric gender-affirming care expressed feeling threatened, “living in consistent fear,” and seeking positions in states without existing or proposed bans on care. 

Even professional societies are considering relocating their conferences or establishing strict planning guidelines to ensure that trans and gender-nonconforming individuals can safely attend. Where does this leave patients and providers in areas with stricter legislation? For many, the future remains uncertain.

Challenges for the clinical lab

Transgender health care is often an area with which laboratorians are less familiar. How should documentation be handled when a patient’s name or gender marker changes? What reference ranges should be used in their evaluations? How might ongoing treatment plans affect their health or lab results? 

“I strongly recommend that every healthcare professional have a working knowledge of trans healthcare laws, regulations, and policies as they relate to your individual work environment."

Between our evolving understanding of trans patients’ physiology and ongoing changes to laws, regulations, and best practices surrounding gender-affirming care, it’s no surprise that many clinical laboratory professionals aren’t sure how to protect both themselves and their patients.

“Everyone needs to keep in mind that trans health care is a dynamic, fast-changing regulatory and legislative environment,” advises Allen. “I strongly recommend that every healthcare professional have a working knowledge of trans healthcare laws, regulations, and policies as they relate to your individual work environment. Laboratory professionals need to understand what is applicable for specimen labeling, documentation, and billing.” 

Anticipating further legislative activity, Allen suggests identifying a legal representative who can keep groups or institutions apprised of relevant changes. He also points out that gender-affirming care is itself a work in progress. “It will be important to understand the impact of new medical treatments and surgical procedures on the laboratory—and how the lab can evolve in response to benefit our patients.”

Allen’s final words are directed at every member of the clinical lab: “Never underestimate the impact each one of us has on our transgender patients’ experiences. It’s imperative that we continue to provide a welcoming, secure diagnostic and therapeutic environment for all—including our trans patients.”