Texas directive on gender-affirming care puts patients and providers at risk, says NEJM


Boram Kim


In a recent perspective piece for the New England Journal of Medicine (NEJM), Anna Kirkland, J.D., Ph.D, Professor of Health Policy at the University of Michigan School of Public Health, outlined how the legal risks from anti-transgender measures like the directive issued by Texas Governor Greg Abbot would pressure physicians to refrain from treating patients.


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Abbott ordered the Department of Family and Protective Services in February to investigate instances of gender-affirming treatments and procedures being performed on children as child abuse. The American Civil Liberties Union (ACLU) and Lambda Legal filed a lawsuit on behalf of transgender children and their families seeking to block the statewide directive. The issue is now heading to court.

In the NEJM article, Professor Kirkland wrote: 

“The Abbott directive and other state anti-trans measures rely on physicians’ risk aversion and uncertainty to drive overcompliance (such as providing HIPAA disclosures that are not required) and withdrawal from care provision. But risk is everywhere when medical, professional, and legal obligations are deliberately drawn into conflict with one another. Patients bear risks when physicians withdraw care or report them to police or child-welfare investigators, and we all share risk when trust in medical providers breaks down.”

The Texas 3rd District Court of Appeals reinstated an injunction last month against state investigations of alleged child abuse by families and physicians who are engaged in gender-affirming care.

Judge Amy Clark Meachum will preside over the legal challenge to Abbott’s directive and hear the full merits of the case on July 11th.

The American Medical Association issued opposition to legislation targeting gender-affirming care last year as state governments introduced proposals to ban such practices.

Republicans have led efforts nationwide to impose restrictions on the LGBTQ community, in particular transgender children. Measures banning school instruction about queer people, gender-affirming care for those under age 18, and participation in sports by transgender youth have passed in various states.

The Florida Department of Health issued new guidance this week advising against gender-affirming care for transgender kids. Republican leaders argue that such practices are experimental and tantamount to child abuse, contrary to recommendations from major medical organizations.

The American Academy of Pediatrics has cited gender-affirming care as vital to the health of LGBTQ youth and recommended the promotion of clinical access to care for both providers and patients.

“These political and legal challenges to the profession will be felt unequally, but the reverberations of politicized mistrust will harm everyone who needs to be able to tell a doctor the truth about themselves, as well as any doctor who needs to hear it, Kirkland wrote.