A federal judge has blocked a Wisconsin school district from requiring transgender students to use bathrooms and locker rooms that match the sex they were assigned at birth while a lawsuit plays out against the school.
U.S. District Judge Lynn Adelman said Thursday that the Mukwonago Area School District must allow a transgender student to use facilities that align with their gender identity, temporarily blocking a policy approved last month by the school board, the Milwaukee Journal Sentinel reported.
The order comes in a lawsuit brought anonymously by an 11-year-old transgender student and her mother. The judge ruled that the school’s policy was causing emotional and mental harm to the student, who was described as a boy at birth but has identified as a girl since she was three years old.
Mukwonago Area School District offices in Mukwonago, Wisc.Google maps
According to court documents, school officials have monitored which bathrooms the student uses and forced her to go to boys’ bathrooms or gender-neutral bathrooms at Mukwonago High School, where she is enrolled in summer school classes.
Adelman ruled that the student’s case was likely to succeed at trial, citing a similar case in Kenosha in 2017, in which a judge held that a school could not block a transgender student from using bathrooms that matched their gender identity.
The Village of Mukwonago is located in conservative Waukesha County, a Milwaukee suburb that has been key to Republican victories in the state. Across the country, Republican lawmakers have passed measures in recent years to restrict which bathrooms transgender students can use in public schools and universities.
On an early morning in June, Flower Nichols and her mother set off on an expedition to Chicago from their home in Indianapolis.
The family was determined to make it feel like an adventure in the city, though that wasn’t the primary purpose of the trip.
The following afternoon, Flower and Jennilyn Nichols would see a doctor at the University of Chicago to learn whether they could keep Flower, 11, on puberty blockers. They began to search for medical providers outside of Indiana after April 5, when Republican Gov. Eric Holcomb signed a law banning transgender minors from accessing puberty blockers and other hormone therapies, even after the approval of parents and the advice of doctors.
At least 20 states have enacted laws restricting or banning gender-affirming care for trans minors, though several are embroiled in legal challenges. For more than a decade prior, such treatments were available to children and teens across the U.S. and have been endorsed by major medical associations.
Indiana Gov. Eric Holcomb in Indianapolis on Jan. 10.Darron Cummings / AP file
Opponents of gender-affirming care say there’s no solid proof of purported benefits, cite widely discredited research and say children shouldn’t make life-altering decisions they might regret. Advocates and families impacted by the recent laws say such care is vital for trans kids.
On June 16, a federal judge blocked parts of Indiana’s law from going into effect on July 1. But many patients still scrambled to continue receiving treatment.
Jennilyn Nichols wanted their trip to Chicago to be defined by happy memories rather than a response to a law she called intrusive. They would explore the Museum of Science and Industry and, on the way home, stop at a beloved candy store.
Preserving a sense of normalcy and acceptance, she decided — well, that’s just what families do.
Navigating new laws
Families in Indiana, Mississippi and other states are navigating new laws that imply or sometimes directly accuse them of child abuse for supporting their kids in getting health care. Some trans children and teens say the recent bans on gender-affirming care in Republican-led states send the message that they are unwelcome and cannot be themselves in their home states.
For parents, guiding their children through the usual difficulties of growing up can be challenging enough. But now they are dealing with the added pressure of finding out-of-state medical care they say allows their children to thrive.
In the Nichols family alone, support took many forms as they traveled to Chicago: a grandmother who pitched in to babysit Flower’s 7-year-old brother, Parker, while their father Kris worked; a community of other parents of trans kids who donated money to make the trip more comfortable.
“What transgender expansive young people need is what all young people need: They need love and support, and they need unconditional respect,” said Robert Marx, an assistant professor of child and adolescent development at San José State University. Marx studies support systems for LGBTQ and trans people aged 13 to 25. “They need to feel included and part of a family.”
In Indiana, rancorous legislative debates, agitated family relationships and exhaustive efforts to find care have drawn families to the support group GEKCO, founded by Krisztina Inskeep, whose adult son is transgender. Attendance at monthly meetings spiked after the state legislature advanced bills targeting trans youth, she said.
“I think most parents want to do best by their kids,” Inskeep said. “It’s rather new to people, this idea that gender is not just a binary and that your kid is not just who they thought at birth.”
The perceptions of most parents, Marx said, don’t align neatly with the extremes of full support or rejection of their kids’ identities.
“Most parents exist in a kind of gray area,” Marx said. “Most parents are going through some kind of developmental process themselves as they come to understand their child’s gender.”
‘This is just like who I am’
On June 13, Flower and Jennilyn set off on their trip, unsteady but hopeful. They brought a care plan from Indiana University’s Riley Children’s Hospital, the Hoosier State’s only gender clinic.
At the time, the pair worried whether Chicago providers could meet their request for full-time support or as a backup if Indiana’s ban went on hold. They considered whether they could make the drive every three months, the necessary interval between Flower’s puberty blockers.
The decision for Flower to start puberty blockers two years ago wasn’t one the family took lightly.
Jennilyn recalled asking early on whether her daughter’s gender expression was permanent. She wondered if she had failed as a mom, especially while pregnant — was it an incorrect food? A missed vitamin?
Ultimately she and Kris dismissed those theories, ungrounded in science, and listened to their daughter, who recalled the euphoria of wearing princess dresses at an early age. Flower cherished a Little Red Riding Hood cape and felt certain of her identity from the start.
Flower Nichols in Chicago on June 13.Teresa Crawford / AP file
“I remember that I really disliked my name,” Flower said of her birth name. “This is just like who I am. It’s all that I have a memory of.”
Conversations between Flower and her mother are often marked by uncommon candor, as when discussing early memories together at an Indianapolis park.
“Before I knew you and before I walked this journey with you,” Jennilyn told her, “I would not have thought that a kid would know they were trans or that a kid would just come out wired that way. I always thought that that was something adults figured out, and so there were times that it was really scary because I didn’t know how the world would accept you. I didn’t know how to keep you safe.”
Now, Jennilyn said, her worries have shifted to Flower’s spelling skills and how she’ll navigate crushes.
Flower, for her part, appreciates being heard. She said she and her parents make medical decisions together because, “of course, they can’t decide on a medicine for me to take.”
“At the same time, you can’t pick a medicine that we can’t afford to pay for or that, you know, might harm you,” Jennilyn responded.
“That’s what I really like about her,” Flower said, of her mother. “She leaves a lot of my life up to me.”
‘They’re ripping our lives apart’
In Mississippi, a ban on gender-affirming care became law in the state on Feb. 28 — prompting a father and his trans son to leave the state at the end of July for Virginia. There, he can keep his health care and continue to see doctors.
“We are essentially escaping up north,” said Ray Walker, 17.
Walker lives with his mother, Katie Rives, in a suburb of Jackson, the state capital. His parents are divorced, but his father also lived in the area. Halfway through high school, Walker is an honors student with an interest in theater and cooking. He has a supportive group of friends.
When Mississippi Republican Gov. Tate Reeves signed the bill banning hormone therapy for anyone younger than 18, he accused “radical activists” of pushing a “sick and twisted ideology that seeks to convince our kids they’re in the wrong body.”
Mississippi Republican Gov. Tate Reeves signs Mississippi House Bill 1125 to ban gender-affirming care in the state for anyone younger than 18 on Feb. 28 in Jackson.Rogelio V. Solis / AP file
The state’s largest hospital halted hormone treatments for trans minors months before Reeves signed the ban. That hospital later closed its LGBTQ clinic.
After that clinic stopped offering its services, Walker and other teenagers received treatment at a smaller facility in another city, but those services ended once the ban took effect.
As access to gender-affirming dwindled and was later outlawed, Walker’s father, who declined to be interviewed, accepted a job in Virginia, where his son could keep his health care. Walker plans to move in with his father this month. Rives, however, is staying in Mississippi with her two younger children.
Walker’s memories of the anguished period when he started puberty at 12 still haunt him. “My body couldn’t handle what was happening to it,” he said.
After a yearslong process of evaluations, then puberty blockers and hormone injections, Walker said his self-image improved.
Then the broad effort in conservative states to restrict gender-affirming care set its sights on Mississippi. The path toward stability that Walker and his family forged had narrowed. It soon became impassable.
Ray Walker, 17, left, and his mother, Katie Rives, discuss his moving to Virginia for continued gender-affirming care on June 28 in Madison County, Miss.Rogelio V. Solis / AP file
“I was born this way. It’s who I am. I can’t not exist this way,” Walker said. “We were under the impression that I still had two years left to live here. The law just ripped all of that up. They’re ripping our lives apart.”
The family sees no alternative.
“Mississippi is my home, but there are a lot of conflicting feelings when your home is actively telling you that it doesn’t want you in it,” Walker said.
As Walker’s moving date approaches, Rives savors the moments the family shares together. She braces for the physical distance that will soon be between them. Her two younger sons will lose Ray’s brotherly presence in their daily lives.
She still feels lucky.
“We know that’s an incredibly privileged position to be in,” Rives said of her son moving to Virginia. “Most people in Mississippi cannot afford to just move to another state or even go to another state for care.”
‘She belongs’
Flower, initially dispirited by the debates at the Indiana Statehouse, brightened after her parents took her to her first Pride march on June 10 in Indianapolis.
She tied a transgender pride flag around her shoulders and covered her pink shirt in every rainbow heart-shaped sticker she could find. She gripped a sign that read: “She belongs.”
Her favorite activities are often less inflected with politics than her status as a soon-to-be teenager. She’s a Girl Scout who enjoys catching Pokemon with her brother. Before the trip, she zipped around an Indianapolis park on a pink scooter, her hair tangled by the wind.
Flower Nichols and her mother, Jennilyn, in front of the Museum of Science and Industry in Chicago on June 13.Teresa Crawford / AP file
Prior to entering Chicago’s Museum of Science and Industry, Flower used a women’s bathroom. At a diner in the city, she ordered a mint chocolate chip milkshake and a vegan grilled cheese. Jennilyn created an itinerary to make their experience as joyful and uncomplicated as possible.
“First of all, we’re going be able to chill at the hotel in the morning,” Flower said. “Second of all, there’s a park nearby that we can have a lot of fun in. Third of all, we might have a backup plan, which is really exciting. And fourth of all: Candy store!”
The doctor’s appointment the following day, initially intimidating, soon gave them another reason to celebrate: If care was not available in Indiana, they could get it in Chicago.
“Indiana could do whatever the hell they’re going to do,” Jennilyn said, “and we can just come here.”
Kansas Attorney General Kris Kobach (R) has filed a lawsuit to force the state government to discriminate against trans people on their driver’s licenses and birth certificates.
The suit asks the court to demand the Department of Revenue’s Division of Vehicles comply with S.B. 180, a sweeping new anti-trans law that, among other things, bans trans people from updating the gender marker on their birth certificates and driver’s licenses.
This is Kobach’s latest move in an ongoing battle between himself and the state’s Democratic Gov. Laura Kelly.
In April, Kelly vetoed S.B. 180, but the state’s Republican-led legislature overrode her veto to pass the bill. Once the bill took effect on July 1, Kelly directed state agencies to continue to allow transgender citizens to change the gender markers on their birth certificates and driver’s licenses in defiance of Kobach.
A banner at the top of the Department of Revenue’s website declares that the “enactment of Senate Bill 180 on July 1 will not impact the longstanding procedures for obtaining, renewing, and updating a Kansas driver’s license as they pertain to gender markers.”
Kobach – who also lost to Kelly in the 2018 gubernatorial race – also filed a motion in June to end a 2019 consent decree settling a 2018 lawsuit brought by four transgender residents who claimed that the state’s refusal to correct birth certificates violated their constitutional right to equal protection.
In conjunction with that motion, Kobach announced that trans people who already had a birth certificate or license changed could keep the documents but that the state’s data would revert back to their sex assigned at birth.
Prior to Kobach’s announcement, legal experts had assumed that the state would not move to change gender markers that had already been updated under the 2019 consent decree, leading many transgender Kansans to rush to update their documents before the law was scheduled to take effect.
Kobach’s current lawsuit against the Department of Revenue blasts Kelly, declaring she “cannot pick and choose which laws she will enforce and which she will ignore.”
“She does not possess the power that English monarchs claimed prior to the ‘Glorius Revolution’ of 1688,” the suit continues, “namely, the power to suspend the operation of statutes.”
Yet Kobach has also been accused of failing to enforce the law in his attempt to retroactively remove gender markers from the documents of trans citizens who received their licenses before the law took effect.
American Civil Liberties Union of Kansas executive director Micah Kubic told KMUW that S.B. 180 does not require the measures Kobach has announced. “These are of his own volition and interpretation, driven by his own extreme ideological perspective, not by requirements of the law, the constitution, or the best interests of Kansans.”
“The laws should not be considered retroactive,” UMKC Law School professor Steve Leben told KCTV5 News. “The law itself says it’s effective July 1, takes effect and it’s enforced from that date.”
Kobach also argues in the lawsuit that the state has already been using sex and gender synonymously since state statute says driver’s licenses must reflect an individual’s “gender” but the actual documents issued use the word “sex.”
Today, only three days after Kobach filed the lawsuit, District Judge Teresa Watson ordered the Kansas Department of Revenue to immediately stop allowing gender changes. The order will last up to two weeks but can be extended as the hearing goes on.
S.B. 180 has been characterized as a “women’s bill of rights” by Republican supporters who claim it is necessary to keep transgender women and girls out of women’s restrooms and locker rooms. In addition to legally defining “sex” in terms of reproductive biology, the law also bans trans people from accessing facilities that correspond with their gender identity in schools, prisons, women’s shelters, rape crisis shelters, and locker rooms.
Days after the Supreme Court’s ruling that businesses can deny same-sex wedding services if it clashes with their religious views, new data says most American voters disagree with that position. Last week, the nation’s high court sided with a Colorado business owner who argued a state non-discrimination law could not compel her to make same-sex websites.
The survey, conducted by Data for Progress, found 65% of voters believe businesses should not be allowed to turn away customers who are of a particular sexual orientation because of the business owner’s personal beliefs.
Many anti-LGBTQ bills introduced and passed in state houses in recent years were pushed by the Alliance Defending Freedom, a Christian legal advocacy group. In the 303 Creative v. Elenis case, the CEO and president of the ADF argued before the high court on behalf of the web designer.
Per the poll’s crosstabs, 64% of Republicans “strongly agree” or “somewhat agree” that businesses should be able to refuse services for same-sex marriages.
For Democrats, the number is 19%.
Around 40% of Republicans also say that businesses should be able to refuse services for interracial marriages and interfaith marriages.
For Democrats, that number is 15%.
Asked about baby showers for unwed mothers, 35% of Republicans says businesses should be able to refuse to provide services.
A transgender woman and former inmate who was held in solitary confinement for six years is suing the Missouri Department of Corrections (MODOC) for what is described as its “unconstitutional and discriminatory policy against people living with HIV.”
The plaintiff, identified only as Jane Roe, claims in the lawsuit filed last week she was held in solitary confinement between 2015 and 2021 at the Jefferson City Correctional Center (JCCC) because she was living with HIV. She is represented by Lambda Legal, the MacArthur Justice Center, and the law firm Shook, Hardy & Bacon
“No person should be subjected to the inhumane and devastating effects of long-term solitary confinement, conditions that Ms. Roe faced every day for more than six years,” Richard Saenz, Lambda Legal senior attorney, criminal justice and police misconduct strategist, said in a statement. “We filed this lawsuit to hold the Missouri Department of Corrections accountable for its use of an unconstitutional and discriminatory policy that singles out people living with HIV.”
“Ms. Roe was trapped in isolation with no way to challenge her conditions,” MacArthur Justice Center attorney, Shubra Ohri, said. “Six years of that led Ms. Roe to self-harm, suicidal ideation, and actual suicide attempts. This tracks with widespread consensus among the human rights experts, psychologists, physicians, and mental health authorities who say solitary confinement is torturous and should be abolished.”
“We seek justice for our client who endured six years of unwarranted solitary confinement. We will work to prevent this from ever happening to another human being,” Gregory Woo, a Shook partner, said in a statement.
The lawsuit, Roe v. Precythe, et. al., was filed in the U.S. District Court for the Western District of Missouri, and claims “MODOC’s policy on incarcerated people living with HIV lacks any consideration of modern medicine and does not engage in individualized assessments.”
The lawsuit alleges that MODOC’s policies and actions violated Roe’s Eighth and Fourteenth Amendments, the Americans with Disabilities Act, and Section 504 of the Rehabilitation Act. Roe claimed she was denied the services, programs, and activities offered to other inmates because of her HIV status. Roe is seeking policy changes by MOCOD, monetary damages, and other unspecified relief.
If you are having thoughts of suicide or are concerned that someone you know may be, resources are available to help. The 988 Suicide & Crisis Lifeline at 988 is for people of all ages and identities. 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.
The bar where police raids sparked the 1969 Stonewall uprising has revealed why it stopped serving Bud Light – and it has nothing to do with calls for a boycott over the beer brand’s collaboration with trans influencer Dylan Mulvaney.
Co-owners of New York’s Stonewall Inn, Stacy Lentz and Kurt Kelly, have revealed that the bar turned its back on Bud Light’s parent company, Anheuser-Busch, in 2021.
At that time, the bar staged a “Keep Your Pride” campaign, which involving refusing to serve products of companies that claimed to be allies of the queer community but which also donated funds to anti-LGBTQ+ individuals.
“The reason we did that… was because they were out there waving the rainbow flag very vehemently, then turning around and contributing to anti-LGBTQ legislators, which can’t happen,” Lentz told Newsweek. “Our communities are fed up with that.”
Lentz said Bud Light’s collaboration with Mulvaney, who has 12 million followers on TikTok, “makes sense” and warned other businesses: “If you don’t market to Gen Z, then in 20 years or 30 years, your business will not exist because Gen Z is all about equality. Your consumer is ageing out.”
The backlash to the collaboration “was ridiculous,” and “the fact that they catered to it was alarming,” she added.
“But at the same time, they at least made an effort. I thought it was a great campaign.”
Dylan Mulvaney was the victim of a transphobic backlash over her social media collaboration with Bud Light. (Credit: Getty Images)
Anheuser-Busch faced a deluge of attacks from anti-trans people after they sent Mulvaney a single personalised can to celebrate the first anniversary of her “Days of Girlhood” TikTok series.
However, despite Target, Bud Light and Innocent Drinks being among the brands to face boycott calls over LGBTQ+ inclusion, stats show that most Americans appreciate and value queer people being featured in advertising.
According to GLAAD’s Accelerating Acceptance survey, 75 per cent of straight people feel comfortable seeing LGBTQ+ in advertising, while 60 per cent of heterosexuals agree that seeing queer people in ads makes them more comfortable with those who are different to themselves.
On Wednesday, Democratic North Carolina Gov. Roy Cooper vetoed a trio of anti-trans bills passed by wide margins in the Republican-controlled state House and Senate. The three bills would ban gender-affirming care for minors, prohibit trans athletes in school sports, and limit classroom discussions about gender and sexuality.
Despite the governor’s vetoes, prospects for killing the legislation are poor. Republicans hold veto-proof majorities in both state chambers.
Cooper condemned the bills as “a triple threat of political culture wars” and accused Republicans of “scheming for the next election” at the expense of vulnerable children.
“A doctor’s office is no place for politicians,” said Copper, echoing a popular line of defense among Democrats defending trans minors. “North Carolina should continue to let parents and medical professionals make decisions about the best way to offer gender care for their children.”
“Ordering doctors to stop following approved medical protocols sets a troubling precedent and is dangerous for vulnerable youth and their mental health,” Cooper said, referring to H.B. 808, which would ban puberty blockers and hormone therapy for trans youth in the state.
Cooper also vetoed H.B. 574, a ban on athletes competing on middle school, high school, and college sports teams that align with their gender identity. A “student’s sex shall be recognized based solely on the student’s reproductive biology and genetics at birth,” the bill reads. Sports teams would be designated for males, men or boys; females, women or girls; or coed or mixed by those strict gender definitions.
The third bill vetoed by Cooper, S.B. 49, would ban instruction on “gender identity, sexual activity, or sexuality” in kindergarten through fourth grade and require parents to be notified “prior to any changes in the name or pronoun used for a student in school records or by school personnel.”
Cooper denounced that measure as hampering “the important and sometimes lifesaving role of educators as trusted advisers when students have nowhere else to turn.”
Conservatives in North Carolina were trailblazers, pioneering the transphobic moral panic that has swept red states in the last two years.
In 2016, the state’s notorious “bathroom bill,” which banned trans people from public restrooms and shut down local efforts to enact anti-discrimination measures, cost North Carolina millions in lost business and was a national embarrassment. The law was partly repealed in 2017.
While Cooper’s vetoes will likely be overridden, activists hold out hope the courts will intervene, as they did then, on at least some of the legislation.
More than 20 states have enacted bans on gender-affirming care for minors, but almost all face court challenges. In June, a federal judge struck down Arkansas’ ban as unconstitutional, and federal judges have temporarily blocked bans in Alabama, Indiana, Kentucky, and Tennessee. Plaintiffs in Florida won a reprieve when a federal judge there blocked enforcement for three minor children.
Max Adomat considers themself fortunate. Adomat, 26, who is nonbinary and uses they/them pronouns, has been on a steady regimen of feminizing hormones for the last six years. They also began their gender transition in New Jersey, a progressive state where clinics offering transition-related medical care are commonplace, and name changes are confidential, they said.
But Adomat still found themself obtaining and self-administering gender-affirming hormones from unregulated, and oftentimes illegal, overseas online pharmacies instead of licensed medical offices. The reason, Adomat said, was a lack of both health insurance and money: When they began transitioning, their low-paying job in the food service industry did not provide insurance, and they were unable to afford the steep cost of transition-related care — including hormone therapy and routine doctors appointments — without it.
Though they knew the risks — which, without supervised care, can include higher chances of blood clots, heart attacks and some cancers — Adomat felt their window for a successful transition was closing, they said.
“I just sort of decided, ‘I’m going to do it, and if and when I can see a doctor somewhere down the road, sure, but I would rather do it now and face those consequences,’” they recalled, adding that their alternative at the time was to continue to “live miserably.”
Max Adomat, 26, has been on a steady regimen of feminizing hormones for the last six years.Max Adomat
Interviews with health care providers and lawyers, as well as transgender individuals who use or have used a do-it-yourself approach to transitioning, suggest the reasons people opt for the nonprescription and self-administration route vary and include cost savings, health care accessibility, medical discrimination, and the desire to choose which hormones and dosages are involved in the process.
A DIY approach, however, is not without its health and legal risks. Despite the risks, some experts predict this approach will become even more common given the current political climate: Nearly 20states have already passed laws blocking access to gender-affirming care for minors, and other states have proposed measures that would restrict this type of care for some adults.
Out of pocket costs
A monthly supply of common feminizing hormones — including estrogen and anti-androgens — can cost patients up to $115, according to GoodRx, which tracks U.S. drug prices. Masculinizing hormones, including injectable testosterone, are typically cheaper, costing about $40 to $90 a month. Through unregulated online pharmacies, however, a monthly supply of these feminizing and masculinizing hormones can be purchased for as low as $8, plus shipping.
While price sensitivity to health care costs is not unique to transgender people, this community faces higher rates of economic hardship and poverty, with 1 in 3 trans adults reporting an annual household income under $25,000, according to a 2021 report from the liberal think tank Center for American Progress.
Samme Qandil, 28, was on a medically supervised hormone regimen for three years, but when she landed a new job and her health insurance changed, she was unable to pay her new provider’s $300 copay for a six-week supply of injectable hormones. Faced with both high copay fees and a nationwide shortage of injectable estrogen, she decided to begin purchasing her hormones from an unregulated online pharmacy recommended by her friends.
While Qandil, now a graduate student in Oregon, said she didn’t have many reservations about obtaining and administering hormones by herself, since she knew others who had gone through the process, she still undergoes regular blood tests to ensure her estrogen levels are within a safe range.
The prescription route cost her nearly $700 a year for medications and $400 in appointment copays, Qandil said — more than twice what she now pays for a two-year supply of hormones and related expenses like estrogen blood tests.
While hormone replacement therapy using a DIY approach is “cheaper and technically more accessible,” Qandil said, orders from overseas pharmacies can be unreliable, with some packages of unregulated hormones seized at the U.S. border. However, she added, DIY is cheaper even with the sunk costs, and she even has the ability to stock up on a yearly supply to ensure the hormones don’t run out during a shortage or customs confiscation.
“In an era when patients may have no option but to ‘DIY’ their transitions, just as it is happening with abortions in many states, it might be important for them to know that there are ways to do it that are overall less risky.”
DR. URI BELKIND, CALLEN-LORDE COMMUNITY HEALTH CENTER
Stephanie Coiro, a clinical social worker at Northwell Health’s Center for Transgender Care in New Hyde Park, New York, estimates about 10% of her transgender patients have tried acquiring hormones without a prescription at one time or another. She said this route can cut their costs by more than 50%. Though, she emphasized, those with a prescription, even if they do not have health insurance, can get testosterone or estrogen for $20 to $30 a month at stores like Target and Walmart with manufacturer coupons.
For those who do not have health insurance, anything out-of-pocket, including doctors appointments, is “incredibly expensive,” Coiro acknowledged. In addition to price concerns, she said recent shortages of hormones, like testosterone, could also drive patients to acquire medication through nonprescription means.
The cost of hormones is often one of many expenditures associated with a transition, according to experts and those receiving transition-related care. And a number of transition-related services and procedures are typically not covered by health insurance, including hair removal, which can be mandatory for some gender-affirming surgeries; therapy visits for referral notes, which are typically mandatory for prescriptions and surgeries; and gender-affirming facial and chest surgeries.
Dr. Uri Belkind, the associate director of adolescent medicine at Callen-Lorde Community Health Center, an LGBTQ-focused health clinic in New York City, called the long list of transition-related expenses a “transgender tax” that can cost trans people hundreds of thousands of dollars over their lifetime.
Across the pond, in the United Kingdom, Alicia Tuplin West, 19, has turned to unregulated online pharmacies for both cost and expedience. While England offers free gender-affirming care through a publicly funded health care system, West, a university student, said she faced a waitlist of up to several years through England’s National Health Service (joining around 26,000 others, according to The Guardian). Unwilling to wait and unable to afford a private health care alternative costing 1,000 pounds a year ($1,250), West bought hormones through an online pharmacy and cut the price by 90%, she said.
“The traditional way, it’s all socialized; it’s all paid for by my taxes,” West said. “However, I would argue that the traditional way is like a myth — the idea of getting treatment from the NHS — if you want to transition in this decade.”
Access to care
Most U.S. states still permit minors to obtain gender-affirming care with parental consent, and, for those over 18, this type of care is still legal in all 50 states. However, recent years have seen an unprecedented wave of state laws seeking to ban or restrict transition-related care, particularly for trans youths.
Eighteen states now have laws on the books banning or restricting the prescription of puberty blockers and hormones to minors, though a federal judge struck down Arkansas’ law last month, and judges have temporarily blocked laws in Alabama, Florida, Indiana, Kentucky, Oklahoma and Tennessee. At least two dozen other statesare considering such measures, and a few, like Tennessee and Oklahoma, have considered bills that would restrict this type of care for some adults.
This legislative push makes legal access to gender-affirming care nearly impossible for some people, three experts told NBC News, which could lead them to unregulated online pharmacies.
Belkind said this recent legislation “absolutely” has the potential to send more transgender people online to seek hormones. He also pointed to a recent request by Florida Gov. Ron DeSantis, a Republican, that asked state universities to send information to the governor’s office about students who sought or received treatment for gender dysphoria.
“People are not going to want to be on those lists for obvious reasons,” Belkind said. “They might not even disclose to their medical providers, if they seek medical care for other things, that they are on hormones.”
Dr. Danielle Brooks, an endocrinologist at Northwell Health’s Center for Transgender Care, said state legislation restricting transition-related care will likely drive more people, including minors, down the DIY path.
“I think more and more people are aware of the path,” Brooks said. “I do think that will be something that will increase over time, and it’s probably increasing now.”
Dr. Joshua Safer, director of the Center for Transgender Medicine and Surgery at Mount Sinai in New York City, said patients have historically self-medicated when they don’t have access to conventional medical care. While he doesn’t think most trans youths will be able to acquire gender-affirming hormones through the informal economy, he said parents may resort to seeking medical care in other states if they have the resources.
If these youths are unable to acquire hormones, Safer said, there are “going to be negative mental health implications.”
The data supports Safer’s assertion: Transgender and gender-nonconforming individuals are at an increased risk for mental illness and suicidality, according to a study published last year in JAMA Network Open, and receipt of transition-related care is associated with 60% decreased odds of moderate or severe depression and 73% decreased odds of suicidality.
Even for adults and minors who have health insurance and live in states not affected by restrictions on transition care, insurance companies may not approve coverage for such care.
Dale Melchert, a staff attorney at the Transgender Law Center, said he has seen most insurance companies oscillate gender-affirming health care coverage based on what’s required under federal regulation, such as individual presidential administrations’ interpretation of the Affordable Care Act. While Obama-era policies blocking widespread coverage exclusions have historically prompted insurers to adjust their plans to cover more gender-affirming care, Trump-era rollbacks of these policies have since barred many from affordable access to transition care, Melchert said.
“Most insurance companies will do anything they can to save money, and denials are a way to save money,” he said. “Technically, we still have Trump’s rollbacks on the books.”
Apart from the expenses associated with transitioning, unpleasant experiences with health care providers can also dissuade individuals from seeking supervised care.
“Doctors can also ask unnecessary questions that have nothing to do with the reason they came to seek care. That feels really invasive,” Melchert said. “A lot of times doctors don’t know how to provide competent care.”
A 2018 study of students at 10 medical schools found that approximately 80% of survey respondents felt “not competent” or “somewhat not competent” treating transgender patients. According to the same study, while 93% of respondents felt somewhat or very comfortable treating sexual minority patients, 68% felt comfortable treating gender minority patients.
Dr. Ricardo Correa, an associate professor at the University of Arizona College of Medicine-Phoenix, acknowledged that there’s a “high” amount of bias in the health care community against trans people, echoing a sentiment also expressed by Brooks. However, he added, even those who want to refer patients to practices where they can receive gender-affirming care may be unable to, because the patients are based in communities where there’s an absence of physicians who are able to provide adequate help.
“Instead of food deserts, there are medical deserts,” Correa said. “The patient just gets more traumatized [and] trusts the system less.” This, he said, can lead patients to pursue a DIY approach, until they are able to find the care they seek.
A desire for control
A., a postdoctoral fellow in life scienceat a Canadian university who requested that her name not be published due to safety concerns, sourced gender-affirming hormones through overseas online pharmacies for roughly a year. She wasn’t, however, prompted by a desire to save money or a lack of health insurance. Instead, she said, her driving factor was control over her own transition.
She said she received care from a Planned Parenthood clinic in the Midwest for nearly three years, followed by care at the LGBTQ nonprofit Howard Brown Health in Chicago for several years. Eventually, she grew dissatisfied after facing remasculinization and plateauing effects, she said. Her decision to take a DIY approach was the result of a conservative approach to hormone replacement therapy by her previous health providers and a general lack of information about trans care among doctors, she said.
“At first, everything seemed to be doing fine,” she said of her transition-related care. “You see breast growth, you see that your skin is getting smoother. … All of a sudden, for no reason whatsoever, you stall or you start regressing. Your facial and body hair come back in force, and you feel general discomfort in your body and mind.”
Following years of remasculinization — including “$3,000 of laser hair removal out the window” and persistent gender dysphoria — she grew desperate for a solution, she said. That’s when she decided to turn to online pharmacies, which enabled her to increase her hormone dosage.
She said the DIY process made her “feel empowered.”
“You feel very lost, but you feel that there’s the possibility of something moving forward,” she said. “You feel like you’re taking the reins of your care.”
After a year of ordering hormones through unregulated online pharmacies and self-administering, she said, she finally found a “good, private” clinic that was willing to listen to her concerns and address her needs. While she no longer personally uses a DIY approach, she continues to serve as a resource for others starting their DIY journeys through online forums, she said.
Health and legal risks
Obtaining and administering hormones without regulated pharmacies and licensed health care providers can expose individuals to serious health risks, including blood clots, stroke, liver damage and cardiovascular disease.
“We’re always worried about excess dosing if someone’s not being monitored, because the risks are real,” Brooks said. “There’s a possibility that medical history is not being taken into account or there is something being missed.”
Brooks said several patients have come to her office with a higher-than-normal concentration of red blood cells as a result of taking “very inappropriately” high levels of testosterone. This, she added, can cause vision problems, dizziness, fatigue, weakness, confusion and, of most concern, blood clots.
“The vast majority of products offered through online pharmacies are, at best, non-U.S. FDA-approved medicines and, more often, at worst, dangerous fakes.”
LIBBY BANEY, ALLIANCE FOR SAFE ONLINE PHARMACIES
Belkind, of Callen-Lorde, said his colleagues have seen patients who ended up with injection-site infections after self-administering hormones using the wrong technique, as well as blood clots due to using the incorrect hormone dosage.
On the flip side, Belkind said, he has had patients who, prior to seeking his care, used self-prescribed hormones and found helpful resources online, where they “learned what medications are safer.”
“In an era when patients may have no option but to ‘DIY’ their transitions, just as it is happening with abortions in many states, it might be important for them to know that there are ways to do it that are overall less risky and that there are resources created by the community where they can learn how,” he said.
Libby Baney, a partner at the law firm Faegre Drinker and a senior adviser to the Alliance for Safe Online Pharmacies, a nonprofit that combats illegal online drug sellers, cautioned that those who buy medication from unregulated online pharmacies may not actually be getting what they ordered.
“U.S. consumers buying medications from online pharmacies rarely, if ever, receive exactly what they think they are ordering,” she said. “The vast majority of products offered through online pharmacies are, at best, non-U.S. FDA-approved medicines and, more often, at worst, dangerous fakes.”
The National Association of Boards of Pharmacy’s 2022 “Rogue Rx Activity Report,” which Baney’s team shared with NBC News, cites a 2008 European Alliance for Access to Safe Medicines report that found 62% of medicines purchased online are substandard or counterfeit, and a 2010 Korean study that found 26% of medications tested from online pharmacies contained toxins like mercury, lead and arsenic, while 37% of samples tested didn’t have any active ingredients at all.
“Anytime that you have a product where people have either a legitimate medical need or perceived need, people will go online to find it outside the regulated supply chain,” Baney said.
Of the approximately 30,000 to 40,000 online pharmacies around the globe, 96% don’t require a valid prescription, 85% offer medicines that aren’t authorized by the FDA and more than 50% offer controlled substances, according to the 2022 National Association of Boards of Pharmacy report.
When it comes to the legal risks, enforcement efforts generally aren’t targeted at individual consumers, but rather the unregulated pharmacies selling the medication or the intermediaries helping to facilitate importation, according to Carrie Harney, vice president of government and regulatory affairs at United States Pharmacopeia, a nonprofit that annually publishes standards for prescription and over-the-counter drugs.
As for Adomat, they have recently scrapped the DIY method in favor of medically supervised care in Pennsylvania. This decision, they said, came after a career switch that included health insurance coverage. Still, Adomat said, they wouldn’t change their five-year DIY experience if given the opportunity.
“My attitude for a while was, ‘If it ain’t broke, don’t fix it,’” Adomat said. “Adding on to a general distrust of doctors, I decided to continue to put it off and shoulder the costs and risks myself.”
Now, with the right insurance and doctor, Adomat said, they “pay a fraction” of what they did using DIY methods. But, they added, those aren’t the only reasons why they’re currently content with the state of their care and their health: “I’m grateful I have a supportive family and legislature around me.”
If you or someone you know is in crisis, call 988 to reach the Suicide and Crisis Lifeline. You can also call 800-273-8255, text HOME to 741741 or visit SpeakingOfSuicide.com/resources for additional resources.
A Kansas law will reverse gender markers on trans people’s birth certificates and driving licences, in a move deemed “disastrous” for those affected.
On Monday (26 June), state attorney general Kris Kobach confirmed to reporters that the new law – Senate Bill 180 – which takes effect from 1 July, will legally erase trans people’s gender identities.
Kobach said the law will also force public schools to record students as the gender assigned at birth, regardless of whether teachers and staff recognise gender identities of trans and non-binary students.
The legislation, described by the Kansas Senate as a “women’s bill of rights,” defines “sex” as “either male or female at birth” in state law, with no alternative definition for individuals who identify as trans, non-binary, gender fluid, or gender-non-conforming.
In addition, trans people will be forced to use toilets and other single-sex spaces corresponding to the gender they were assigned at birth.
Republican representative Brenda Landwehr, who voted for the bill, said it would “protect women’s spaces currently reserved for women and men’s spaces currently reserved for men”.
‘That does not make you a woman’
Senator Renee Erickson, one of three Republican lawmakers who joined Kobach during his news conference, said: “You can choose whatever name you want. You can choose to live however you want. That does not make you a woman.”
The law follows a 2019 ruling which saw a federal judge order Kansas to allow trans people to change their birth certificates to settle a lawsuit over a no-change policy. SB 180 would see the 2019 order cancelled.
Micah Kubic, the executive director of the American Civil Liberties Union of Kansas, accused Kobach of rushing to “impose his own stamp of extremism”. He added that state agencies are not required to adopt the attorney general’s views.
‘Disastrous and fraught with difficulty’
Trans activist and journalist Erin Reed, whose partner is trans Montana lawmaker Zooey Zephyr, said of the new law: “Rolling back transgender people’s legal markers would be disastrous and fraught with difficulty.”
Reed said enforcing incorrect gender markers could lead trans people to experience heightened “harassment and abuse”.
In May, Montana’s Senate Bill 458 was signed into law. The Republican-backed legislation defines “sex” as binary – excluding intersex, non-binary and trans people.
Zephyr has been vocal in opposing Republican’s anti-LGBTQ+ bills, which saw her banned from the floor of the state’s House of Representatives.
‘Calculated manoeuvre’
Reed added: “The calculated manoeuvre of redefining sex to systematically exclude transgender individuals is an attempt to sidestep legal challenges. These laws represent a clear attempt to move beyond targeting transgender youth and the beginning of the campaign to eradicate transgender adults from all legal protections.”
According to AP News, Omar Gonzalez-Pagan, a lawyer for Lambda Legal, said: “The attorney general must be off his rocker. This was a bunch of bombast by an attorney general engaging in politics.”
A survey has found that a slim majority – just over half – of LGBTQ+ people in the UK feel comfortable being “out” in the workplace.
The study by consultancy firm Deloitte found that 52 per cent of the 402 LGBTQ+ Brits polled were comfortable being openly queer at work, compared to 43 per cent of the 5,474 LGBTQ+ people polled worldwide.
The survey also found that 43 per cent of LGBTQ+ people in the UK fear being seen differently by their straight, cisgender colleagues, compared to 39 per cent of respondents globally.
Deloitte polled queer people from 13 countries for the survey, and nearly half of the British respondents (49 per cent) reported being discriminated against at work due to their sexuality or gender identity.
Thirty-eight per cent said they had come up against homophobic or transphobic behaviour – including sexual jokes – at work.
Phil Mitchell, co-lead for the Deloitte LGBTQ+ staff network Proud, said: “When people feel that their employers aren’t doing enough to support inclusion or are not taking non-inclusive behaviours seriously, many instances go unreported.
“Employers should take action to ensure that they provide a positive culture of LGBTQ+ inclusion, underpinned by respect.”
Of the LGBTQ+ 18 to 25-year-olds polled for the survey, 19 per cent added that they had been bullied in the workplace, while the study also found that LGBTQ+ young people are paid less than their straight, cisgender peers on average.
Amy Ashenden, interim CEO of Just Like Us, said: “Our research shows that the treatment of LGBT+ people in British society today is preventing young adults from thriving at work.
“LGBT+ young people deserve to safely be themselves at school, home and work – there must be no exceptions.”
