A History of American Legal Barriers to Gender-Affirming Care

The last 5 years in the United States have witnessed a flurry of policies attempting to limit access to gender-affirming care (GAC), with state and federal authorities instituting restrictions on care for transgender and gender-diverse (TGD) adolescents and attempting to limit funding for treatment costs. Although many have decried these policies as an unprecedented assault on GAC, there is actually a long history of attempts to limit access to GAC in the United States through the creation of restrictive policies directed at patients, clinicians, and payers. Even amid such restrictions, TGD people have demonstrated a remarkable ability to access GAC, often finding new ways to obtain this care. These have included shifts in tactics deployed by advocates of GAC as hostile policymakers attempted to limit the expansion of access. The current landscape of restrictive policies represents the culmination of a longstanding regulatory evolution, integrating various legislative approaches that have been used over almost a century. This article discusses how TGD communities have navigated several iterations of hostile legislative environments to access such care.