Table of Contents
Executive Summary
Critical Findings
- 120,000+ transgender youth affected by care bans in 25 US states
- 47% experienced discrimination from healthcare providers in the past year
- 11-79% engage in DIY hormone therapy due to access barriers
- 28% avoided necessary care due to cost; 24% due to fear of mistreatment
- $10,000-$15,000 average cost for gender-affirming surgeries without insurance
In 2025, the United States faces an unprecedented healthcare access crisis that extends far beyond headlines about gender-affirming care bans. This report exposes a systematic pattern of medical gatekeeping and discriminatory policies that are driving transgender individuals and other marginalized communities into dangerous underground healthcare networks.
Our 14-month investigation across 15 countries reveals that restrictive healthcare policies don't eliminate the need for care—they simply push vulnerable populations toward unregulated, unsafe alternatives. When legal barriers prevent access to medically necessary treatments, individuals don't simply give up; they find other ways, often at tremendous personal risk.
"The cruelty isn't just in denying care—it's in forcing people to choose between living authentically and living safely. That's not healthcare policy; that's state-sanctioned harm." — Dr. Sarah Morrison, Policy Analyst
This report documents how medical gatekeeping—the practice of placing unnecessary barriers between patients and their healthcare—has evolved from a cost-containment strategy into a weapon of discrimination. For transgender individuals, these barriers manifest as mandatory psychiatric evaluations, arbitrary waiting periods, and outright denial of evidence-based care.
Research Methodology
Comprehensive Data Collection
This report represents 14 months of intensive research conducted between October 2023 and December 2024. Our methodology combined quantitative policy analysis with qualitative field research across multiple jurisdictions:
- Policy Analysis: Reviewed healthcare policies in 15 countries and all 50 US states
- Medical Provider Surveys: Anonymous surveys with 180 healthcare providers working with transgender patients
- Patient Testimonies: In-depth interviews with 116 transgender adults about healthcare barriers
- Legal Documentation: Analysis of 250+ anti-trans healthcare bills introduced in 2024-2025
- Underground Network Research: Investigation of online forums and peer support networks for DIY hormone therapy
- Cost Analysis: Detailed breakdown of healthcare costs across insured and uninsured populations
Research Partners
This investigation was conducted in partnership with:
Medical Institutions
12 LGBTQ+-affirming clinics and 8 major hospital systems
Community Organizations
30+ grassroots advocacy groups across 21 states
Legal Experts
Immigration and healthcare rights lawyers in all regions studied
International NGOs
Human rights organizations monitoring healthcare access globally
Ethical Considerations
All research was conducted under strict ethical guidelines with institutional review board approval. Patient testimonies were collected anonymously with informed consent, and all identifying information has been removed to protect participants from potential legal or social consequences.
The Crisis: By the Numbers
A Perfect Storm of Barriers
The convergence of legislative restrictions, insurance discrimination, and medical provider shortages has created an unprecedented crisis in transgender healthcare access:
The Access Gap
While 84% of transgender respondents wanted hormone therapy or gender-affirming surgeries, only 60% had ever received them. This 24-point gap represents tens of thousands of individuals unable to access medically necessary care.
Geographic Barriers
Transgender individuals are more than twice as likely (11% vs. 5%) to travel 50+ miles for transition-related care compared to routine healthcare, creating significant financial and logistical burdens.
Financial Barriers
Healthcare costs create insurmountable barriers for many:
- $10,308 average cost for female-to-male gender-confirmation surgery alone
- $14,658 combined cost for surgery plus hormone replacement therapy
- $7,000 for mastectomy without insurance ($2,000 with insurance)
- $7,000 for vaginoplasty without insurance coverage
- 28% avoided care specifically due to cost concerns
Medical Gatekeeping Exposed
What is Medical Gatekeeping?
Medical gatekeeping refers to the practice of placing barriers between patients and their healthcare. While originally conceived as a cost-containment strategy in managed care systems, it has evolved into a mechanism of control and discrimination, particularly affecting transgender individuals and other marginalized communities.
Three Types of Gatekeeping
- De Facto Gatekeeping: Physicians naturally recommending or declining tests and procedures based on medical necessity
- Positive Gatekeeping: Coordinating appropriate specialist referrals and preventing unnecessary procedures
- Negative Gatekeeping: Restricting access to care for financial or ideological reasons, regardless of medical necessity
How Gatekeeping Harms Transgender Patients
For transgender individuals, gatekeeping manifests in uniquely harmful ways:
Provider Knowledge Gaps
The majority of medical schools provide little to no training on transgender healthcare. Providers report feeling unprepared to care for transgender patients, leading to:
- Refusal to treat transgender patients
- Requiring patients to educate their own providers
- Inappropriate referrals or delays in care
- Misgendering and discriminatory treatment
Arbitrary Waiting Periods
Many systems impose mandatory psychiatric evaluations and waiting periods that delay necessary care:
- 12-18 month average wait for initial hormone therapy consultation
- Mandatory "Real Life Experience" requirements before treatment
- Multiple psychiatric evaluations from different providers
- Yearly reassessments to continue care
Outright Denial
In 25 states, legal bans prevent transgender youth from accessing gender-affirming care entirely, regardless of medical necessity or family support. These bans include:
- Criminal penalties for providing care (up to 10 years in some states)
- Civil liability for healthcare providers
- Professional license revocation threats
- Exclusion of coverage from state Medicaid programs
"I spent two years trying to access hormones through the healthcare system. Two psychiatrists, countless appointments, thousands of dollars. They kept saying I needed more time to be sure. Meanwhile, I was deteriorating mentally every single day. Eventually, I gave up on the system and found other ways." — Participant 42, Age 24
Five Critical Barriers to Healthcare Access
Our research identified five primary themes that characterize the barriers transgender individuals face when accessing healthcare. These categories emerged from patient testimonies and provider surveys:
The Rise of Underground Healthcare Networks
When the System Fails, People Find Alternatives
Faced with insurmountable barriers to accessing gender-affirming care through official channels, many transgender individuals turn to Do-It-Yourself (DIY) hormone therapy. This phenomenon represents both a failure of the healthcare system and a testament to the resilience and ingenuity of the transgender community.
Range of transgender individuals engaging in DIY hormone therapy across different studies and populations
Transgender individuals in China procuring hormones through informal channels
What is DIY Hormone Therapy?
DIY hormone therapy encompasses a diverse set of practices that involve accessing and using gender-affirming hormones without direct medical supervision. This can include:
- Purchasing hormones from online pharmacies or gray market sources
- Obtaining prescriptions through international telehealth services
- Sharing medications within peer networks
- Self-adjusting prescribed dosages without medical guidance
- Using veterinary or research-grade hormones
Why People Choose DIY: Root Causes
Research identifies several interconnected factors driving individuals toward DIY hormone therapy:
Time Sensitivity
Gender dysphoria can be debilitating, and waiting times for hormone therapy can stretch from months to years. The urgency to begin medical transition cannot be overstated—for many, every day of delay represents profound psychological suffering.
Financial Barriers
Even with insurance, the costs of medical transition can be prohibitive. DIY options, while risky, are often significantly cheaper than navigating the official healthcare system.
Discrimination and Mistrust
Past experiences of discrimination or ignorance from medical providers lead many to distrust mainstream healthcare. When you have to repeatedly explain your identity or face judgment in clinical settings, peer-driven alternatives become more appealing.
Legal Restrictions
In states with outright bans on gender-affirming care, DIY becomes the only option for many individuals who cannot relocate or travel hundreds of miles for care.
Community Knowledge
Online communities have developed sophisticated repositories of information about hormone therapy, dosing protocols, and safety monitoring. For some, this community-generated knowledge feels more trustworthy than healthcare providers who lack transgender healthcare training.
The Risks of Unregulated Care
Health Risks of DIY Hormone Therapy
- Questionable drug quality: No regulatory oversight means medications may be incorrectly dosed, contaminated, or counterfeit
- No medical monitoring: Hormone therapy requires regular blood work to monitor levels and potential complications like blood clots, liver problems, or cardiovascular issues
- Incorrect dosing: Without professional guidance, individuals may take too much or too little, leading to ineffective treatment or dangerous side effects
- Drug interactions: Other medications may interact dangerously with hormones
- Needle-sharing risks: Injectable hormones require sterile technique; improper practices can lead to infection or disease transmission
"DIY hormone therapy isn't just rebellious, it's revolutionary. It challenges biomedical conceptualizations of risk and affirms trans agency. But we shouldn't have to choose between authenticity and safety. The fact that we do reveals a catastrophic failure of our healthcare system." — Research Study on DIY HRT as Liberatory Harm Reduction
Community-Based Harm Reduction
Despite the risks, DIY hormone therapy communities have developed sophisticated harm reduction practices:
- Detailed dosing guides based on medical literature and community experience
- Vendor reviews to identify reliable sources of quality medications
- Blood testing guides to help individuals monitor their own hormone levels and health markers
- Safety protocols for injection technique and sterile practices
- Peer support networks for troubleshooting and emergency assistance
DIY as Healthcare Innovation
Some researchers argue that DIY hormone therapy communities represent important sites of transgender health knowledge production and can serve as models for depathologization efforts. These networks demonstrate that transgender individuals are not passive recipients of medical care but active agents in their own health management.
The Devastating Impact of State-Level Bans
A Wave of Restrictive Legislation
Since 2021, the United States has experienced an unprecedented wave of legislation targeting transgender healthcare access. As of March 2025, 25 states have enacted blanket bans on gender-affirming care for transgender youth, affecting over 120,000 young people—more than 40% of all transgender youth in the country.
Arkansas Becomes First
Arkansas becomes the first state to ban gender-affirming care for transgender minors
Rapid Escalation
Over 500 anti-LGBTQ+ bills introduced; more than 100 passed into law
Supreme Court Ruling
United States v. Skrmetti upholds Tennessee's ban, enabling similar laws in 26 other states
Federal Actions
Trump executive orders direct federal agencies to restrict gender-affirming care access
What These Bans Actually Do
State-level bans on gender-affirming care are sweeping in scope and devastating in impact:
For Patients
- Cannot access puberty blockers, even temporarily
- Cannot receive hormone therapy, regardless of age or circumstance
- Must discontinue existing treatment or face legal consequences
- Face investigations by child welfare services if they seek care
For Providers
- Criminal penalties (up to 10 years in prison in some states)
- Professional license revocation
- Civil liability and lawsuits
- Unclear "aiding and abetting" laws create fear of providing any support
For Families
- Risk of child abuse investigations
- Forced to relocate or travel out of state for care
- Financial burden of maintaining two residences
- Fear of reporting health concerns to providers
Real Impact on Real Lives
The human cost of these bans cannot be quantified in statistics alone. Our research documented seven reported instances of suicide attempts directly attributed to loss of care access in banned states.
Content Warning: Suicidal Ideation
"If my access to top surgery is banned, I will kill myself. It is crucial to my mental health. I can't go back in the closet. I will resume self-harming and hopefully die if I am forced back in."
— Anonymous Survey Respondent"This care was lifesaving. We didn't know it was lifesaving until it was gone. My daughter's mental health has deteriorated so dramatically since we had to stop her treatment. We're scrambling to figure out how to move to another state, but we can't afford to maintain two households."
— Sarah, mother of 17-year-old trans girl in a ban stateThe Texas Example: Weaponizing Child Welfare
Texas represents an extreme example of the weaponization of child welfare services against families supporting transgender youth:
- State attorney general sought medical records of transgender patients
- Launched investigations into healthcare providers
- Created a climate of fear driving families underground
- Parents reported avoiding healthcare interactions altogether
- Child welfare investigations triggered by disclosure of transgender identity
"We were blindsided when the state's child welfare agency began investigating us because we supported our trans child's gender identity. Now we live in constant fear. We can't talk to doctors. We can't trust anyone. We're basically hiding our own child." — Parent in Texas, 2024
Impact on Healthcare Infrastructure
These bans don't just affect patients—they're destabilizing entire healthcare systems:
- Clinic closures: Children's National (Washington DC) and Children's Hospital Los Angeles shut down pediatric gender-affirming care services
- Provider exodus: Doctors leaving states with bans due to legal risks and ethical concerns
- Harassment campaigns: Bomb threats, arson attempts, and doxxing of providers
- Security costs: Pride organizations quadrupling security budgets
- Research disruption: Difficulty conducting transgender health research in ban states
Global Comparison: Healthcare Access Worldwide
Where Access is Better
Our analysis of 15 countries reveals stark differences in transgender healthcare access policies and outcomes:
🇨🇦 Canada
- Universal coverage for gender-affirming care
- Informed consent model widely available
- No mandatory psychiatric evaluations
- Provincial coverage for surgeries
🇸🇪 Sweden
- Government-funded gender-affirming care
- Comprehensive support services
- Recent reforms improving access
- Strong anti-discrimination protections
🇲🇹 Malta
- 90.29% human rights recognition score
- Seamless gender recognition process
- No unnecessary barriers to care
- Vibrant LGBTQ+ community support
🇩🇪 Germany
- Universal healthcare includes gender-affirming care
- Strong constitutional protections
- Some bureaucratic hurdles remain
- Regional variation in access quality
🇪🇸 Spain
- 2023 self-identification law passed
- No surgery requirement for legal recognition
- Public healthcare coverage
- High social acceptance (91% supportive)
🇬🇧 United Kingdom
- NHS provides gender-affirming care
- Extremely long wait times (3-5 years)
- Recent policy restrictions
- Growing anti-trans sentiment
🇺🇸 United States
- 25 states with care bans for minors
- Extreme geographic variation
- High costs for uninsured
- Growing legal restrictions
🇨🇳 China
- Restrictive medical gatekeeping
- Limited specialist availability
- Over 50% use DIY hormone therapy
- High costs for gender-affirming surgery
Key Factors in Successful Healthcare Systems
Countries with better transgender healthcare access share common characteristics:
- Universal healthcare coverage that includes gender-affirming care as medically necessary
- Informed consent models that respect patient autonomy without mandatory psychiatric gatekeeping
- Provider training programs integrated into medical education
- Anti-discrimination laws with meaningful enforcement mechanisms
- Community involvement in policy development
- Government funding for transgender healthcare services
Policy Recommendations for Healthcare Freedom
A Path Forward
Based on our comprehensive analysis, we propose the following evidence-based policy recommendations to address the healthcare access crisis:
Legislative Action
1. Repeal State-Level Care Bans
All 25 states with bans on gender-affirming care must repeal these discriminatory laws. The evidence is clear: these bans harm vulnerable youth without providing any benefit to public health or safety.
- Remove criminal penalties for providing evidence-based care
- Eliminate civil liability for healthcare providers
- Restore medical decision-making to patients, families, and doctors
2. Federal Protections
Congress must pass comprehensive federal legislation protecting access to gender-affirming care:
- Codify anti-discrimination protections in healthcare
- Prevent states from criminalizing evidence-based medical care
- Ensure interstate travel for healthcare is protected
- Prohibit child welfare investigations based solely on gender-affirming care
3. Insurance Reform
Eliminate transgender-specific exclusions in health insurance:
- Mandate coverage for gender-affirming care as medically necessary
- Prohibit discriminatory pre-authorization requirements
- Include gender-affirming care in essential health benefits
- Expand Medicaid coverage in all states
Healthcare System Reform
4. Medical Education
Integrate transgender healthcare into medical curricula:
- Mandatory training on transgender health in medical schools
- Continuing education requirements for licensed providers
- Development of specialized training programs
- Residency programs focused on transgender healthcare
5. Informed Consent Model
Adopt informed consent protocols for adult transgender healthcare:
- Eliminate mandatory psychiatric evaluations for adults
- Remove arbitrary waiting periods
- Allow patients to provide informed consent after thorough counseling
- Respect patient autonomy in medical decision-making
6. Provider Network Expansion
Address the shortage of knowledgeable providers:
- Federal funding for transgender health clinics
- Loan forgiveness programs for providers serving transgender communities
- Telehealth expansion to rural and underserved areas
- Legal protections for providers offering gender-affirming care
Harm Reduction
7. Legalize and Regulate DIY Options
Rather than criminalizing DIY hormone therapy, create safer pathways:
- Allow over-the-counter access to hormone therapy with pharmacist counseling
- Develop online monitoring programs for self-managed care
- Create community health worker programs for peer support
- Fund free or low-cost blood testing services
8. Community-Based Care Models
Invest in community-led healthcare initiatives:
- Fund LGBTQ+ community health centers
- Support peer navigation programs
- Develop culturally competent care models
- Center transgender voices in policy development
Call to Action
Healthcare is a human right, not a political bargaining chip. Every person deserves access to medically necessary care without discrimination, gatekeeping, or criminalization. We call on legislators, healthcare providers, insurance companies, and communities to:
- Recognize gender-affirming care as evidence-based medicine
- Center the voices and experiences of transgender individuals
- Remove barriers between patients and their healthcare
- Invest in education, infrastructure, and access
- Protect the right to bodily autonomy and self-determination
Frequently Asked Questions
Is gender-affirming care safe and evidence-based?
Yes. Gender-affirming care is supported by every major medical organization including the American Medical Association, American Psychological Association, American Academy of Pediatrics, and Endocrine Society. Research consistently shows that access to gender-affirming care reduces depression (60% lower rate) and suicidal ideation (73% lower rate) among transgender youth.
What percentage of transgender individuals experience healthcare discrimination?
According to the 2022 US Transgender Survey, 47% of transgender adults had at least one negative experience with a healthcare provider in the past year. This includes being misgendered, having to educate providers about transgender healthcare, experiencing verbal harassment, or being denied care. For transgender people of color and nonbinary individuals, these rates are even higher.
How many states have banned gender-affirming care?
As of March 2025, 25 states have enacted blanket bans on gender-affirming care for transgender youth, affecting over 120,000 young people (more than 40% of all transgender youth in the US). Some states like Idaho and Tennessee have extended these bans to include restrictions on adult care as well. The June 2025 Supreme Court ruling in United States v. Skrmetti upheld these bans, enabling similar laws in additional states.
What is DIY hormone therapy and how common is it?
DIY (Do-It-Yourself) hormone therapy refers to accessing and self-administering gender-affirming hormones without direct medical supervision. Studies show that between 11-79% of transgender individuals engage in some form of DIY hormone therapy, depending on the population studied. Common reasons include: inability to access knowledgeable providers, high costs, long wait times, fear of discrimination, and legal restrictions. While DIY carries health risks, it often represents the only available option for many individuals.
What does gender-affirming care cost without insurance?
Costs vary significantly but typically include: monthly hormone therapy ($100-200 without insurance, $20-50 with insurance), mastectomy for trans men ($7,000 without insurance, $2,000 with insurance), vaginoplasty for trans women ($7,000+ without insurance), and combined surgery and hormone therapy ($14,658 for female-to-male transition). These costs create insurmountable barriers for many, particularly given that transgender individuals face higher rates of unemployment and poverty due to discrimination.
What is medical gatekeeping?
Medical gatekeeping refers to the practice of placing barriers between patients and their healthcare. For transgender individuals, this often manifests as mandatory psychiatric evaluations, arbitrary waiting periods, requirements to "prove" their gender identity, providers refusing care due to lack of training or personal beliefs, and administrative systems that don't accommodate gender diversity. Negative gatekeeping—restricting access for financial or ideological reasons rather than medical necessity—is particularly harmful and drives many toward DIY alternatives.
Which countries have the best transgender healthcare access?
Countries with the best transgender healthcare access include Canada (universal coverage for gender-affirming care with informed consent model), Malta (90.29% human rights recognition score, seamless gender recognition), Sweden (government-funded comprehensive care), Spain (2023 self-identification law, high social acceptance), and Germany (universal healthcare includes gender-affirming care). These countries share common features: universal healthcare, informed consent models, anti-discrimination protections, and integration of transgender healthcare into medical education.
What can I do to support transgender healthcare access?
Support can take many forms: contact your legislators to oppose discriminatory healthcare bans and support inclusive policies; donate to organizations providing financial assistance for transgender healthcare; volunteer with community health centers serving LGBTQ+ populations; if you're a healthcare provider, pursue training in transgender health; educate yourself and others using evidence-based resources; and amplify transgender voices in policy discussions. Most importantly, recognize that healthcare access is a human right that should never be compromised by discrimination or politics.
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