Journal Club: The Health Impacts of Anti-Trans Legislation
A 2024 paper explores the mental health impacts of anti-trans legislation on trans people.
by Veronica Esposito
Over the past four years, an unprecedented number of bills have been filed targeting the rights and safety of transgender individuals. Independent journalist Erin Reed has tracked well over 1,100 such bills in the years 2023 through 2024 alone.
Bills passed into law include measures to prevent trans people’s access to bathrooms, to ban gender-affirming healthcare, to prevent trans people from having accurate documentation of and identification bearing their gender, and to legally erase the existence of trans people. According to the Movement Advancement Project, at least 9 states have signed laws establishing criteria for sex that is discriminatory against trans people, by linking it to birth-assigned sex, chromosomes, or reproductive ability. In addition, states such as Florida and Texas have taken extra-legislative means to prevent essential aspects of transition, like updating gender markers on driver’s licenses, and have even gone so far as to compile databases of transgender people and their medical care.
This legislative assault has impacted the mental health of trans people—both those who have lost rights directly due to these laws and those who may feel threatened by their mere existence. A survey by the National Center for Transgender Equality found that nearly half of respondents had considered moving away from their current state of residence due to anti-trans legislation, while 5% of respondents already had. Human Rights Campaign estimates that nearly 40% of transgender children live in states impacted by bans on appropriate medical treatment, meaning that over 100,000 transgender children are potentially directly impacted by this legislation. Prior reporting by myself has detailed the impacts of such legislation on trans people in a relatively “safe” state such as California.
In a major new study published in the prestigious journal Nature, Lee et al., found significant associations between the enactment of laws targeting transgender individuals and suicide attempts by transgender youth. Tracking multiple time periods surrounding debate and enactment of anti-trans laws in all 50 states, as well as in Washington, D.C. and Puerto Rico, between 2018 and 2022, the study found clear evidence that anti-trans laws lead to increased suicide attempts. Among trans youth aged 13 - 17, the study found a 7% increase in past-year suicide attempts in the year immediately following anti-trans laws being passed, a 72% increase in the second year, and a 52% increase in the third year. (Referred to as Time period 1, 2, and 3, the exact periods varied somewhat between states due to legislative debate and complexities in the enactment of anti-trans laws.) The study also found significant increases in suicide attempts by those aged 13 - 24.
Notably, this study used “placebo tests” to help ward off criticism that increases in suicide by trans youth might be a coincidence that is due to other causes—these placebo tests looked at impacts of anti-trans laws to full-time employment and homelessness to trans youth, finding no significant impacts. Increasingly common in research in the social sciences when it is not possible to have a typical “control group,” placebo tests are methods for assessing the likelihood that the variable being tested for is the cause of the result found in research, and not some other confounding factor.
The study also controlled for other factors, including race, ethnicity, age, and the impacts of the COVID-19 pandemic on mental health among minors, finding that the results of the study were not meaningfully impacted by these other variables. Lee et al., 2024 is an extremely large study, recruiting 61,240 participants, warding off another potential criticism that is often attached to scientific studies of transgender youth, as studies with small sample sizes are often critiqued as being of lesser scientific value. While no study is perfect, this one comes close to the gold standard for measuring the impacts of legislative change.
Lee et al. found stronger impacts among youth aged 13-17 than among those aged 13-24. The authors theorized that this was due to the reduced medical autonomy of those under 18 years of age, as well as decreased abilities to find meaningful support among peers. This points to deleterious impacts of stigmatizing trans youth, for example in marking them as different by preventing them from playing sports with others of their gender.
Because thoughts of suicide remained relatively constant, while attempts increased, the authors hypothesized that increased suicide attempts were most likely the result of trans youth who had already been contemplating suicide due to other stressors being pushed into an attempt to take their own life by these laws. The authors explained that repeated exposure to intense painful and life-threatening stressors can, over time, erode an individual’s normal fear of death, making suicide an increasingly feasible option, with discriminatory legislation being the last straw.
According to Lee et al., the key factor in increased youth suicide was the enactment of a law—mere debate of such laws did not have the same impact, although they did think there could be spillover effects in neighboring states. Given that only 7 states do not currently border a state with anti-trans bills signed into law, this is potentially a very significant effect.
Another recent study, this one crafted by researchers Lindsay Y. Dhanani and Rebecca R. Totton, spoke to the potential impacts of anti-trans legislation that has merely been debated and not yet enacted, attempting to quantify the impacts of this such legislation on the mental health of transgender individuals. Between September and October 2021, they surveyed 113 trans-identified individuals on their experiences across eight different measures, including depressive symptoms, physical health symptoms, and fear of disclosing their trans status. Dhanani and Totton found associations between consuming news of anti-trans legislation and worsening of mental and physical health, as well as impacts on things like accessing healthcare, the community climate around trans people, and relationships with friends and family.
Importantly, this research demonstrated negative impacts on trans people regardless of whether any anti-trans legislation was enacted. As the researchers put it, “our research emphasizes the symbolic harm created by exposure to the legislation and subsequent community support of this legislation. . . . [N]ews consumption related to the legislation and/or perceptions that socially relevant others support the legislation were associated with a range of deleterious health consequences as well as increased fears of disclosing. Respondents also described that the legislation emboldened people to behave in more discriminatory ways toward transgender people and increased social isolation, fears of personal safety, and identity concealment as a result.”
Over 20% of respondents found that proposed legislation and related media coverage had resulted in an “increase in discrimination, harassment, or other mistreatment.” Respondents told Dhanani and Totton, “People feel more comfortable being disrespectful towards me” and “they have been more hateful and more willing to use harmful language (insults, misgendering, slurs).” Many respondents either feared greater mistreatment in the future or reported increased efforts to avoid disclosing their identity. Notably, of the 60% who perceived no change in treatment, many indicated that this was either because they were already mistreated for being trans or because they actively hid their trans status from others.
Although there had not yet been bans on gender-affirming healthcare when the study was conducted, Dhanani and Totton’s study found that there were adverse impacts on trans individuals, regardless of having any specific legislation on the books. Nearly 3/4 of survey respondents indicated that simply the proposal of legislation had impacted their ability to access necessary healthcare. Notably, of the 26.2% that said the legislation would not change their healthcare, many did so because they already believed their access to medical treatment to be compromised to a meaningful extent.
One respondent told the researchers, “These bills seem to legitimize pathologizing transness, and many med places already seem a bit behind the curve, or even downright bigoted, so that really sucks (and adds to the danger of everything wrong with you being ignored or falsely attributed to your transness).”
Nearly 40% of respondents stated anticipated negative mental health impacts of losing access to gender-affirming medical care, including the potential for suicidal behavior. One respondent stated, “I would kill myself without gender afrming care, it's the only thing worth living for: the potential that some day I might be able to be myself.” Other themes around losing medical care were fears over extreme levels of gender dysphoria, stalling a medical transition in a middle stage, and overall feeling greater stigma at being trans.
Proposed legislation also led to a general deterioration of trust in medical environments and reduced likelihood that trans individuals would seek any form of medical care. Roughly 1 in 8 told the researchers that they would be less likely to pursue medical treatment, would have heightened concerns about discrimination by medical staff, or would have heightened anxiety while pursuing medical treatment. Approximately 1 in 10 said that the proposed legislation would make them hide their trans status from doctors. One respondent stated, “It makes me really hesitant to go to just any doctor. When I do choose a doctor, I almost never disclose my transgender identity in fear of mistreatment or lack of understanding. I don’t want to go to a doctor for [insert whatever medical thing] and have them more focused on my gender than the actual problem at hand.”
Debates around limiting access to gender-affirming care and other anti-trans legislation often attempt to highlight potential harms of trans rights to groups such as detransitioners, women and girls in sports, and transgender youth themselves, while downplaying potential harms of such legislation. Although the trans community has long believed that both the toxic debate around trans existence and actual legislation causes harm, these new studies are important because they demonstrate clear harm to transgender people from anti-trans bills. It offers validation to trans people who have felt their mental and physical health deleteriously impacted in recent years by the constant stream of anti-trans rhetoric and news, and evidence to policymakers who want to stem the tide of these sorts of bills. It is also a reminder to the community to care for itself during a crucial period in the battle for trans rights.
Veronica Esposito (she/her) is a writer and therapist based in the Bay Area. She writes regularly for The Guardian, Xtra Magazine, and KQED, the NPR member station for Northern California, on the arts, mental health, and LGBTQ+ issues.