Intersex young people struggle with their mental health at higher rates than their peers, and how they’re treated by their families and doctors seems to play a part.
Over half of intersex LGBTQ+ youth (55 percent) reported seriously considering suicide in the past year, according to a new report from the Trevor Project, compared to 39 percent of endosex LGBTQ+ youth — those who do not have an intersex condition.
There are several factors that could be contributing to this disparity, says lead author Jonah DeChants, including a “combination of stigma and misplaced shame and embarrassment among individuals and researchers as well.”
“Historically, intersex identities have been unfortunately very much stigmatized,” DeChants tells The Advocate. “Some of that stigmatization came from poorly informed but well-intentioned families and medical providers who felt like in order for their child to have a ‘normal life,’ it was better for them to not know or to not talk about their intersex identity with other people, just like other LGBTQ identities.”
This stigma has “really contributed to a lack of funding for research, a lack of thinking to ask people about their intersex status or having sex differences,” according to DeChants, which is something his team wanted to begin rectifying. Their report surveyed 18,663 LGBTQ+ young people, some as young as 13, finding 256 who identified as both intersex and LGBTQ+ (1.4 percent). Though small in number, the disparities the group reported were vast.
Among intersex youth, 13 percent reported being subjected to some form of conversion therapy, in comparison to only 5 percent of their LGBTQ+ endosex peers. “That’s a really big disparity,” DeChants says, and it’s especially concerning when 43 percent of intersex youth who were subjected to conversion therapy reported a suicide attempt in the past year, compared to only 22 percent who hadn’t experienced conversion therapy.
“We can’t establish a causal relationship in the survey. It’s really a snapshot. We can’t tell which came first, the chicken or the egg, but the fact that there are more chickens and more eggs is still an important relationship to document,” he explains. “The fact that those rates are double really shows that there’s a harmful association between experiencing these things specifically among intersex young people.”
DeChants also noted the “similarities between coercive medical procedures and conversion therapy,” as 17 percent of intersex youth reported experiencing asurgical procedure that altered their anatomy or their reproductive organs to “fit normative expectations based on the gender binary.” Two-thirds of those respondents said that they had not consented to those surgeries, and the median age for such procedures was less than 1 year old.
“We really wanted to highlight the fact that most of those folks did not consent and were not able to consent to those procedures,” DeChants said. “The nonconsensual administration of that health care very early in life is showing a detrimental impact on folks later in life.”
It’s important to keep “educating parents and doctors about the potential harm of these nonconsensual early in life procedures and trying to change the medical protocol and the medical culture around sex differences and intersex identities,” DeChant says, pointing to the work of groups such as interACT that advocate for changes in law and policy.
For those in the lives of intersex youth, he emphasizes that “it would be better to leave that person’s body alone until they have the ability to determine what their gender identity is or decide what medical interventions feel good for them.”
“You do not have to have a body that fits into the gender binary in order to have a ‘normal life’ or to be a happy and healthy adult,” DeChant says.
If you or someone you know needs mental health resources and support, please call, text, or chat with the 988 Suicide & Crisis Lifeline or visit988lifeline.org for 24/7 access to free and confidential services. Trans Lifeline, designed for transgender or gender-nonconforming people, can be reached at (877) 565-8860. The lifeline also provides resources to help with other crises, such as domestic violence situations. The Trevor Project Lifeline, for LGBTQ+ youth (ages 24 and younger), can be reached at (866) 488-7386. Users can also access chat services at TheTrevorProject.org/Help or text START to 678678.
Anti-trans legislation sweeping the country is proving deadly.
A recent study determined that such laws increased suicide attempts among transgender and nonbinary youth by as much as 72%. And that’s just one instance of how LGBTQ+ mental health is on the ballot this election.
Studies overwhelmingly show that queer people are disproportionately likely to experience depression, anxiety, and suicidal ideation or to engage in self-harming behaviors, particularly LGBTQ+ youth. According to the Trevor Project, 41% of queer youth considered taking their own lives within the past year, and an estimated 60% say they were not able to access treatment to care for their psychological and emotional well-being when they needed it. These grave disparities became a topic of national conversation earlier this year after Nex Benedict, a nonbinary Indigenous teen, died one day after being attacked in an Oklahoma high school bathroom. Police say that Benedict took their own life, but family members are pursuing an independent investigation.
The mental health of LGBTQ+ youth and adults is likely to be profoundly affected by the outcome of the 2024 presidential race: If elected to the White House in November, former President Donald Trump has pledged to take federal actionpreventing trans youth from accessing gender-affirming care. His running mate, JD Vance, has called to incarcerate doctors who offer gender-affirming care to young people.
With the election just weeks away, existing data shows that LGBTQ+ Americans, and especially young people, are acutely aware of the potential fallout of a Trump reelection. The vast majority of trans and nonbinary youth (86%) told the Trevor Project that “recent debates around anti-trans bills have negatively impacted their mental health,” per 2023 data from the national youth suicide organization.
LGBTQ+ Americans, and especially young people, are acutely aware of the potential fallout of a Trump reelection.
Hope Giselle, executive director of the National Trans Visibility March, says that she is personally “terrified” about what may be coming next, like many members of the LGBTQ+ community. She wants to believe that voters are “going to do the right thing” but referenced the landmark work of trans pioneers like Marsha P. Johnson and Sylvia Rivera, who were discarded by the mainstream LGBTQ+ movement in the 1970s and 80s as activists pursued a path of assimilationism.
“I want to believe that I should have good faith in folks, but I have seen the way that’s played out for me in the past,” she told LGBTQ Nation. “I’ve seen the way that’s played out for folks that I love. My sisters were at the forefront of this movement and set things up for communities that turned around and booed them at their own rally. Those things can repeat themselves.”
As the LGBTQ+ community nervously braces for an uncertain future, elected leaders are stressing the importance of prioritizing queer mental health as a political issue and raising increased visibility regarding the struggles that some community members are facing. At the federal level, a bipartisan group of lawmakers in the U.S. House of Representatives is pushing the PEER Mental Health Act, which would create grant programs to assist schools in addressing the mental health needs of students. The bill’s lead sponsor, Rep. Becca Balint (D-VT), also introduced the MEND Act, which would provide mental health assistance to local communities following natural disasters, such as those in the Appalachian mountains and Gulf Coast amid the ongoing destruction from Hurricane Helene.
Although the bills don’t specifically name the LGBTQ+ community as an area of focus, Balint says that queer people “get hardest hit” in times of crisis because so many are already living on the margins. LGBTQ+ people are more than twice as likely as the general population to experience homelessness in their lifetimes and also face higher rates of poverty and unemployment.
Even in a progressive state like Vermont, which she has represented in Congress since 2022, Balint often hears from LGBTQ+ youth in rural areas who are struggling without affirming resources. “It might be easier to be queer or trans in New York or San Francisco,” Balint said that young queer people often tell her, “but in my little town, even in Vermont, I don’t feel supported.”
“It’s so important to me because I was one of those young queer people who knew at a young age that I was gay and felt completely and totally out of sorts,” Balint told LGBTQ Nation. “I have struggled with anxiety and depression my whole life. I want to do everything that I can as an elected official, not just to pass a policy that will help young queer and trans people across the country but also to be a role model by talking about [mental health].”
Mental health and the fight for equality
“To state what your needs are and go after them, that’s a strength,” says Minnesota state representative Brion Curran. Photo: Marcus Dorsey/Lexington Herald-Leader/Tribune News Service via Getty Images.
While addressing the myriad and multifaceted mental health challenges queer people face will take nationwide engagement, LGBTQ+ officials say the cost of not addressing the community’s needs is too high. Minnesota state representative Brion Curran (D) knows this first-hand: They began to experience severe PTSD while training as a deputy police officer and ultimately left their profession because they were afraid of “becoming a statistic.” Now that they are in a better place, Curran is vocal about their struggles to help dispel the silence and shame that remains pervasive around the subject. According to the National Alliance on Mental Illness, around 60% of adults who experience mental health issues do not seek treatment, largely due to stigma.
“I’m really open and vocal about people just seeking resources or asking for that support,” Curran told LGBTQ Nation. “That’s not a weakness. To state what your needs are and go after them, that’s a strength. I’m fortunate that I was able to access the resources I need, and I also know that not everybody has those resources.”
Pro-LGBTQ+ legislation, at its core, is mental health legislation.
As an elected official, Curran has sponsored efforts to train therapists to provide appropriate care to first responders and says that the state is working on decreasing burdensome regulations that may prevent people from getting the treatment they need. But they have also been heartened to see the state embrace its role as a safe haven for LGBTQ+ people by passing a law in 2023 declaring Minnesota a refuge for trans youth health care. Curran says that pro-LGBTQ+ legislation, at its core, is mental health legislation because it “encourages positive mental health outcomes for people” who may not have that support from their home states.
Although anecdotal reports from the LGBTQ+ Victory Institute, an organization fighting for increased queer political representation, warned that the mental health of LGBTQ+ electeds could be negatively impacted from constantly fighting on the front lines of equality, Curran maintains that “it’s important to talk about the struggles of specific communities.”
“It’s important to have people with lived experience at the table where decisions are made,” Curran said. “It’s easy for some issues to get overlooked when there’s not a person in the room directly dealing with that issue. In politics, oftentimes, some of these healthcare issues don’t seem really flashy. They might get lost in the mix, and so it’s important that we have people like me with these life experiences in the room so that we can say, ‘Hey, we can’t forget about this.’ ”
LGBTQ+ people are at a noticeably higher risk of “adverse brain health outcomes” in comparison to their straight and cisgender peers — and discrimination could be having an impact.
LGBTQ+ adults are at a 15 percent higher risk of composite brain health outcomes, including dementia, strokes, and late-life depression, according to a new study published in Neurology. Transgender women in particular were found to have higher odds of having strokes.
The study examined data from 393,041 participants with available information on sexual orientation and gender identity, of whom 39,632 (10 percent) identified as some form of LGBTQ+, with 38,528 (97 percent) belonging to a sexual minority and 4,431 (11 percent) to a gender minority.
The report found that LGBTQ+ “persons had higher odds of adverse brain health outcomes,” and that “these results persisted across sexual and gender minorities separately.” It concluded that “further research should explore structural causes of inequity to advance inclusive and diverse neurologic care.”
“It is concerning to see the differences in brain health between sexual gender minority (SGM) individuals and cisgender straight people,” lead author of the study, Shufan Huo, told CNN. “At the same time, I am glad that we can raise awareness for this often overlooked group. Medicine has traditionally focused on white, male patients, but nowadays we realize that this approach does not sufficiently address the needs of our diverse population.”
Huo stressed that the findings do not indicate that simply being LGBTQ+ causes these outcomes. Instead, the trend is made possible by several factors, including discrimination, which can cause stress, depression, and anxiety. Social stigma can also lead to disparities in health care for LGBTQ+ individuals, particularly as they face restrictions on their care from state governments.
Previous reports have demonstrated how discrimination negatively impacts well-being among LGBTQ+ people, as leading cancer research organization the American Cancer Society found in its 2024 Cancer Facts and Figures report that queer people frequently experience “minority stress” in health care settings, leading to an “elevated prevalence” of cancer risk factors.
Team sports are generally regarded to have positive benefits for kids, from gaining a new skill to socialization. However, there are some negatives associated with sports teams, particularly boys’ sports teams, when a culture of toxic masculinity and anti-LGBTQ+ language is present.
A study by Fordham University has shown that when youth are exposed to anti-LGBTQ+ language, it greatly harms them, unsurprisingly. However, the data also showed that it was not young queer children who are the most impacted by anti-LGBTQ+ language in athletic environments. It was young, straight white boys.
Locker room talk with homophobic undertones, phrases like “man up” or “don’t be a sissy,” pressure boys not to act feminine, with deeply harmful results, even if the phrases are used jokingly. Researchers write that language like that is often used in boys’ sports environments, allegedly to motivate. But it often simply ends up “policing,” as the researchers write, the right and wrong way to be a man.
Using language and phrases like that “harms the well-being of everyone,” said Laura Wernick, one of the study’s lead authors and an associate professor of social service at Fordham’s Graduate School of Social Service.
Youth exposed to higher levels of such language did not benefit as much from the positives that youth sports offer compared to their peers who were not exposed to hurtful language. Self-esteem was one of the primary benefits lost when sports environments were inundated with harmful language.
Wernick said that the decrease in self-esteem was significantly greater among straight white cisgender boys than any other subgroup, calling it “the irony of policing masculinity.”
It’s not that LGBTQ+ youth are unaffected by this type of language in youth sports environments. However, researchers suggest that the impact on them and other marginalized groups may be less severe, as their past experiences have often helped them develop coping strategies.
The study was published in the Journal of Sport and Social Issues. Data was collected in 2014 as part of a project started by high school students in Michigan who were a part of Neutral Zone, an organization in Ann Arbor. The LGBTQ+ students who started the project bonded over shared experiences being bullied and were mentored by Wernick, a doctoral student at the time.
About the experience, Wernick said, “This was before a lot of media were starting to pay attention to the experiences of queer and trans youth.Their experiences weren’t being heard or believed.”
The study surveyed students in five urban, rural, and suburban schools about their experiences of harmful language in different environments, such as youth sports.
“I don’t think coaches think about the actual impact it has on boys,” Derek Tice-Brown, an assistant professor of social service at Fordham and the study’s co-lead author, said. “They grew up playing sports the exact same way, and that’s how they were taught to compete, to live up to a certain idea of what manhood is.”
The Florida Department of Education (FLDOE) has ordered local school districts to submit their sex education plans to the state for approval. The FLDOE has also said the classes must promote abstinence and cannot include discussion of contraception or pictures of reproductive health organs.
The sex-ed takeover removes local discretion when it comes to district sex education classes and materials.
For some time, Florida law has mandated that sex-ed lessons emphasize the “benefits of sexual abstinence as the expected standard and the consequences of teenage pregnancy” for grades 6 through 12.
But now the state has removed any local control of additional information school districts can provide their students.
A memo written by Broward County administrators obtained by The Orlando Sentinel summarized the district’s verbal interactions with state officials regarding their takeover of sex ed in the state. The state provided no written instructions provided for districts.
“Pictures of external sexual/reproductive anatomy should not be included in any grade level,” the memo recorded state officials as saying. “Contraceptives are not part of any health or science standard” but could be mentioned as a “health resource,” though “pictures, activities, or demonstrations that illustrate their use should not be included in instruction in any grade level,” it said.
“Different types of sex (i.e., anal, oral, and vaginal) cannot be part of instruction in any grade level,” state officials added, according to the Broward memo.
Orange County schools previously started their lessons in 5th grade with one class devoted to the physical changes of puberty. High schoolers had discussions about contraception and sexually transmitted diseases.
Now the state must approve any additional curriculum and they’ll either deny the additions or ignore them, forcing local districts to cancel sex-ed classes altogether until the state addresses their plans.
Elissa Barr, a professor of public health at the University of North Florida and a member of the sex ed advocacy group Florida Healthy Youth Alliance, has been keeping in touch with local school officials and compiling a list of words and phrases they’ve been told to remove from their reproductive health plans.
These words include abuse, consent, domestic violence, fluids, gender identity and LGBTQ information, she said.
Removing the word “fluids” from lessons will make it hard to teach about how HIV is transmitted, for instance, since it spreads through blood, breast milk, semen and vaginal “fluids”.
“That’s science,” Barr said.
The verbal feedback that Orange school district officials got was plain: Throw out your plan and just use the state textbook.
“The FDOE strongly recommended the district utilize the state adopted text,” the district said in an emailed statement to the Sentinel.
The state textbook preaches abstinence as the only effective way to prevent STDs and pregnancy, and there’s no mention of contraception. The text also encourages students to go on group outings rather than spend time alone with a date.
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Teams of prominent scientists and ethicists have called for the end of medically unnecessary nonconsensual surgeries on intersex children in two new papers.
On the heels of the United Nations Human Rights Council’s first-ever resolution affirming the rights of intersex people, the papers signal growing international resolve to address rights violations experienced by people born with variations in their sex characteristics, sometimes called intersex traits.
Since the 1950s, surgeons have conducted irreversible and medically unnecessary “normalizing” operations on intersex children, such as procedures to reduce the size of the clitoris, which can result in scarring, sterilization, and psychological trauma. Intersex advocacy groups, as well as various medical and human rights organizations, have spoken out against these surgeries for decades. Despite a growingconsensus that these surgeries should end, as well as global progress on banningthem, some parents still face pressure from surgeons to choose these operations for children too young to participate in the decision.
The authors of one of the expert papers found that surgeons’ subjective cosmetic preferences for the appearance of genitals was one of the most commonly reported justifications in the paper’s sampling of elective “normalizing” surgeries on children younger than 10. Cosmetic appearance of genitals has no validated measure, so the data featured surgeons’ subjective descriptions instead. The authors, including five World Health Organization staff members, concluded that, “Legislating and medical regulatory bodies should advocate for ending the conduct of irreversible, elective, ‘sex-normalizing’ interventions conducted without the full, free and informed consent of the person concerned.”
The second paper, co-signed by dozens of professionals around the world, including physicians, ethicists, and psychologists, examined the ethical implications of “normalizing” interventions on children’s genitals. The authors conclude that clinicians “should not be permitted to perform any nonvoluntary genital cutting or surgery on any child, regardless of the child’s sex traits or socially assigned gender, unless doing so is urgently necessary to protect the child’s physical health.”
Both papers advocate that children born perfectly healthy – just a little different – should be free to grow up and make decisions about their own bodies.
The Trevor Project and the Helmsley Charitable Trust announced on Tuesday the trust awarded Trevor $5 million to support a campaign in support of LGBTQ+ youth in the rural Midwest. It comes after the Trevor Project found young queer youth are more than four times more likely to attempt suicide in rural areas than their peers.
Across the country, every 45 seconds, it’s estimated that at least one LGBTQ+ youth attempts suicide, according to the group. The Trevor Project found that 55 percent of LGBTQ+ youth in Montana considered suicide, compared to 45 percent nationwide. In South Dakota, 19 percent of young people surveyed attempted suicide, compared to 14 percent across the country. The organization also found that access to mental health support is lacking among LGBTQ+ youth. In Nevada, 72 percent of LGBTQ+ youth surveyed wanted mental health care in the past year and were not able to get it, Trevor noted.
“Right now, it is as critical as ever to take action to address the public health crisis of suicide among LGBTQ+ young people – especially in rural areas, where suicide risk often remains high while awareness and understanding of the issue may be limited,” Kevin Wong, senior vice president of marketing, communications, and content at The Trevor Project, said in an email to The Advocate. “The urgency is clear, as our most recent research shows that 39% of LGBTQ+ young people seriously considered attempting suicide in the past year — including 46% of transgender and nonbinary young people.”
The campaign will specifically target nine states within the trust’s Rural Healthcare Program: Hawai’i, Iowa, Minnesota, Montana, Nebraska, Nevada, North Dakota, South Dakota, and Wyoming. Funds will also go toward The Trevor Project’s public training team to support 50 training sessions for youth organizations across these states. According to the Trevor Project, this training will be held in areas where there is a higher rate of suicide among youth.
Real stories of LGBTQ+ youth will anchor the campaign, according to the organizations.
“We are immensely grateful to The Helmsley Charitable Trust for helping us maximize The Trevor Project’s reach across audiences in these nine states. It’s an invaluable opportunity for us to leverage a mass reach medium like digital and static billboards, combined with broadcast advertising’s opportunity to connect with linear TV audiences, alongside the unparalleled targeting capabilities of digital platforms such as display ads, programmatic ad buys, as well as paid search and paid social,” Wong said. “The Trevor Project’s messages of hope, affirmation, and support will be carried to youth and adult audiences across different identities and geographies.”
For its part, The Helmsley Charitable Trust’s contribution follows its history of supporting rural health care programs.
“Helmsley is the largest private funder of rural health initiatives in the country. We seek to bring equality and access to care to all people living in rural America – and we care deeply about communities that have historically been overlooked and underresourced. Our work with The Trevor Project fits squarely into our priorities, as this PSA campaign will address the critical issue of mental health awareness and suicide prevention among LGBTQ+ youth in rural areas – a group of young people that is impacted by suicide risk at significantly higher rates than their peers of other demographics,” said Walter Panzirer in an email. “We are thrilled to partner with The Trevor Project because they have a long history of trust within the LGBTQ community. Trevor has always been a staunch advocate for enhancing mental health among the young people they serve, and they bring more than 26 years of demonstrated suicide prevention and crisis intervention success across the country.”
Panzirer noted that the trust has supported other LGBTQ+ groups before including The Golden Rainbow out of Las Vegas and is working with another at the moment — that partnership has not yet been announced.
“Protecting the lives of young people should not be viewed as political or controversial; it should be something that we all support,” Panzirer said in the official announcement.
The Trevor Project said the campaign will start next year.
“We are thrilled to partner with The Helmsley Charitable Trust on this critical endeavor to support the mental health of LGBTQ+ young people across the Midwest at a time when they may need it most,” Jaymes Black, CEO of The Trevor Project said in the announcement. “The Trevor Project’s research has consistently shown that LGBTQ+ young people are at higher risk for suicide compared to their peers, and we have a lot of work to do to connect them with the support they need. This work is especially crucial as we consider the unique barriers that exist for young people in many communities across our nine target states. Together, we look forward to decreasing stigma, educating youth-serving adults, and making it possible for LGBTQ+ young people to lead the happy, fulfilling lives they deserve.”
If you or someone you know needs mental health resources and support, please call, text, or chat with the 988 Suicide & Crisis Lifeline or visit988lifeline.org for 24/7 access to free and confidential services. Trans Lifeline, designed for transgender or gender-nonconforming people, can be reached at (877) 565-8860. The lifeline also provides resources to help with other crises, such as domestic violence situations. The Trevor Project Lifeline, for LGBTQ+ youth (ages 24 and younger), can be reached at (866) 488-7386. Users can also access chat services at TheTrevorProject.org/Help or text START to 678678.
Mpox, the highly infectious disease previously known as monkeypox, has been detected at Fort Dodge Correctional Facility, a prison in Iowa.
The Iowa Department of Corrections (IDOC) has stated that there has been at least one case of Mpox located at the Fort Dodge Correctional Facility.
“We’re actively managing the situation with robust health measures,” IDOC Chief of Staff Paul Cornelius said in a statement to the Des Moines Register, initially reported by KCCI-TV.
“Affected individuals are receiving care, and enhanced sanitation and isolation protocols are in place to prevent further spread.”
It remains unconfirmed how many of the 1,251 inmates have caught the highly contagious disease but the Fort Dodge facility has emphasised that stringent measures are in place to avoid further spread.
Local news outlets are reporting that strict isolation and sanitation measures are being enforced to contain the outbreak.
This is the first case detected in Iowa this year. In 2023, only one case was recorded.
The virus was first declared a global health emergency by the World Health Organization (WHO) in July 2022, after cases increased in Europe and the Americas.
Mpox is broken down into two strains: clade 1 and clade 2. The strain identified at Fort Dodge is clade 2, a less severe version of the disease, however the news that Mpox had been detected at Fort Dodge Correctional Facility led to a spike in Google searches about Mpox clade 1 and what the risks are of it spreading to the US.
While clade 1 is most commonly reported, which has been deadly across Africa, clade 2 is nowhere near as deadly and has a 99.9% survival rate.
Though gay and bisexual men were disproportionately affected by Mpox, it is not a “gay disease” and anyone can catch it.
Mpox has spread around the globe, with 99,518 cases in 122 locations as of August 6, according to the CDC.
Is there a vaccine for this clade of Mpox?
According to the CDC, clade 2 is still circulating but there is a Mpox vaccine that is recommended to be delivered in two doses.
A new study has indicated that getting two doses of the Mpox vaccine works to prevent Mpox.
The vaccination is likely to make the infection milder and reduce the risk of severe infection and death.
It’s very rare for people to get Mpox after they’ve been fully vaccinated, vaccinated people became infected in less than 1% of cases.
However, only 23% of eligible people have received the vaccine.
What are the symptoms of Mpox? (Tchandrou Nitanga/Getty)
What are the early symptoms of Mpox?
There is a lot of misinformation surrounding Mpox so it’s important to know the facts.
Mpox is spread primarily by skin-to-skin contact, Clade 2 symptoms can be initially harder to notice. It usually takes between 5 and 21 days for the first symptoms to appear.
The first symptoms of Mpox includes a high temperature (fever), a headache, muscle aches, backache, swollen glands, shivering (chills), exhaustion and joint pain.
A rash usually appears 1 to 5 days after the first symptoms. It can be on any part of the body, including the palms of the hands, soles of the feet, mouth, genitals and anus.
Symptoms of Mpox typically last two to four weeks but may last longer in someone with a weakened immune system.
Mpox is primarily transmitted through close contact, including intimate or sexual contact, with an infected individual or contact with contaminated materials.
You can read the latest official information about Mpox here.
A major US health insurance company is making artificial insemination available on all its eligible plans – regardless of sexual orientation or partner status.
Aetna, a subsidiary of CVS Health, announced the landmark change its intrauterine insemination (IUI) policy on Tuesday (27 August). Members can access the benefit as a test of fertility and, in some cases, to increase the chances of pregnancy.
“Expanding IUI coverage is yet another demonstration of Aetna’s commitment to women’s health across all communities, including LGBTQ+ and unpartnered people,” the company’s chief medical officer, Cathy Moffitt, said.
“This industry-leading policy change is a stake in the ground, reflecting Aetna’s support of all who need to use this benefit as a preliminary step in building their family.”
Aetna is one of the United States’ largest medical insurance providers, serving over 35 million people and when combined with the rest of CVS Health, makes up 11 per cent of the market share.
What is IUI?
Also known as artificial insemination, IUI is a fertility treatment that involves placing specially prepared sperm directly into the uterus. The procedure is done around the time of ovulation, to increase the chances of fertilisation.
The procedure is usually the first step for couples with unexplained fertility problems, but can also be used for single women and LGBTQ+ couples wanting to start a family. Unlike in vitro fertilisation, where the egg is fertilised in a lab and the embryos then implanted into the uterus, IUI is a direct injection of the sperm.
While IUI is generally less costly, the success rates are lower than IVF, especially for those over the age of 35.
Ground-breaking shift in policy for LGBTQ+ parents-to-be
Aetna’s previous policy only provided IUI treatments to straight couples who said they were not able to conceive after trying for six or 12 months, depending on their ages.
Single women and LGBTQ+ couples were required to pay for 12 cycles of IUI before they became eligible for coverage. The discrepancy was the subject of a 2021 lawsuit brought by a couple in New York.
In response, Aetna, without acknowledging any wrongdoing, committed to ensuring equal fertility treatment coverage for all policyholders, regardless of sexual orientation or marital status. This includes reimbursing past claims for eligible LGBTQ+ individuals and establishing a $2 million (£1.5 million) fund to compensate those affected by the disparity.
Kate Steinle, the chief clinical officer at Folx, an American healthcare provider for the LGBTQ+ community, said: “We know first-hand the barriers people face in accessing medical care to start or grow their families.
“As an in-network provider focused on the LGBTQ+ community, we applaud Aetna’s efforts to reduce out-of-pocket costs, so that more people can have the families they dream of and deserve.”
The new policy comes into effect on Sunday (1 September).
Dr. Molly McClain treats many out-of-state patients at her New Mexico clinic, though she said around 1 in 5 find the cost too prohibitive. Nina Robinson for NBC News
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.
Dr. Kade Goepferd said the waitlist at their Minnesota clinic “has grown every year” and has gotten “particularly long after the bans went into effect.”Sarah Wilmer for NBC News
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.
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 outlawedfor 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.”
Dr. Molly McClain said shield laws are a “tenuous protection” for providers of gender-affirming health care for minors.Nina Robinson for NBC News
The Supreme Court has agreed to hear its first case on gender-affirming carenext 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.
Dr. Molly McClain leads the Deseo clinic, which is run out of the UNM Southeast Heights Family Health Clinic in Albuquerque, N.M.Nina Robinson for 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.
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 Franciscosaid 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.”
Dr. Kade Goepferd said the anti-trans messaging they face in their line of work weighs on them, despite the joy and purpose they’ve found in their profession.Sarah Wilmer for NBC News
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.”
The waiting room at the Children’s Minnesota Specialty Center, where Dr. Kate Goepferd’s Gender Health Program is located.Sarah Wilmer for NBC News
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.”
