Providers’ Beliefs and Values: Understanding Their Approach to Gender-Affirming Care

Study Population

The study included 43 providers (MD, DO, NP, and PA) from 24 states with varying legislation (Table 1). Inclusion criteria consisted of (1) being a medical provider; (2) practicing in the United States; and (3) treating TGD youth. Both specialists and generalists were included, such as those in adolescent medicine, pediatric endocrinology, family medicine, and general pediatrics. Participants practice in various settings, including family practices, community clinics, and those affiliated with gender clinics. We aimed to recruit a sample that was reflective rather than representative, capturing diversity in geographic location, practice setting, career stage, and provider identities.

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Table 1.

State Distribution by Legislation Status.

Legislation status	Number of states included in study
States with a ban	12
States with a shield law	8
States without a ban or shield law	4

Instrument Development

We utilized a phenomenological approach to conceptualizing and conducting this study. The interview guide for this study was developed through a multi-step process to ensure it comprehensively addressed the research project’s objectives. The development of the guide began with an extensive review of existing literature on GAC, provider beliefs, and legislative impacts. This review informed the initial set of questions, ensuring alignment with prior research insights and identification of gaps requiring further exploration.

Subsequent iterations of the interview guide were made based on consultations with subject matter experts, including providers who treat TGD youth and qualitative health researchers. Their feedback was instrumental in refining the phrasing and scope of questions to ensure clarity, relevance, and sensitivity to the diverse practices and perspectives of participants. The iterative process prioritized creating a guide that allowed providers to share their experiences and insights without presupposing uniformity in their practices or beliefs. Special attention was given to streamlining the guide to reduce interview length and cognitive load, thereby lowering participant burden without compromising the depth or breadth of data collection. The instrument ultimately consisted of 20 open-ended questions designed to explore providers’ beliefs, values, and experiences regarding the provision of GAC to TGD youth amidst shifting social and political climates.

Participant Recruitment

The recruitment strategy began with 5 local contacts, each responsible for recruiting 8 to 10 participants, complemented by snowball sampling. States were selected based on differing legislation regarding GAC for minors: Ohio, New York, Massachusetts, Arkansas, and Florida. These states were selected to capture diverse legislative contexts; they represented a mix of states with legislative bans, shield laws, and no legislation (neither ban nor shield law). Shield laws preserve access to GAC by providing legal protections for providers and families from punitive action by other states with legislative bans. These laws vary in specifics from state to state. ¹³ Ohio and New York experienced legislative changes shortly before the study, with Ohio implementing a ban and New York passing a shield law. Massachusetts was chosen due to its comprehensive shield law, while Arkansas and Florida both saw bans overturned by federal judges before the study commenced. Even with the legislative changes during the time from study design to study implementation, these states reflected the different legislative possibilities for GAC bans and protections. Because GAC is a highly politicized and sensitive issue, the reasoning behind this approach was that providers would be more likely to enroll in a study if they were referred by someone they know and trust.

Despite some success, this approach required adjustments. The recruitment ultimately involved a mix of local contacts, snowball sampling, and a listserv dedicated to trans health. The listserv was instrumental in reaching underrepresented areas and demographics. Members of the listserv additionally shared with outside contacts and referred participants. Snowball sampling proved most effective, as participants felt more comfortable being referred by trusted colleagues amid the politically sensitive nature of the study. ¹⁴

Data Collection

The PI conducted 43 semi-structured interviews between May and July 2024. A total of 41 providers explicitly responded to the questions about beliefs and values analyzed in this paper. The open-ended questions allowed participants to discuss perspectives and challenges in providing GAC amidst shifting political and social climates. Interviews continued until data saturation was achieved, providing a comprehensive view of provider experiences. To understand current practices and experiences, it was essential to hear from a range of voices responding to the same questions. The guide included questions such as: (1) What is your position on the provision of GAC to TGD youth? (2) Can you describe the values and beliefs that support that position?

Interviews were conducted via Zoom, recorded with options for participants to turn off cameras. Given the vulnerable nature of the topic and the current political and legal climate, an NIH Certificate of Confidentiality was used to protect participants, with participant confidentiality concerns discussed during the verbal consent process. ¹⁵

Data Analysis

All interviews were transcribed verbatim prior to coding and analysis to ensure accuracy. For data analysis, a thematic approach was employed using ATLAS.ti qualitative coding software (version 25.0.0.32864, ATLAS.ti Scientific Software Development GmbH). An inductive coding strategy was utilized to develop a codebook, which was applied by 3 experienced coders. The coders worked collaboratively to reach consensus and identify common themes across the interview transcripts.

Criteria for Treatment

The most prevalent theme among the 41 providers whose responses are included in this study was criteria for treatment, emphasizing GAC is evidence-based medicine that reduces suffering in TGD youth who meet the criteria for treatment. Providers’ endorsement of GAC as evidence-based reflects a broad consensus within the medical community. They asserted this care aligns with guidelines from the World Professional Association for Transgender Health (WPATH) and support from leading medical organizations such as the American Medical Association and the American Academy of Pediatrics.^{16 -18} Providers practicing in states with bans on GAC provision were most likely to emphasize clinical rigor, with 27 responses highlighting evidence-based medicine compared to 15 in shield law states and 7 in states with no legislation. Similarly, the importance of consistent diagnosis and addressing patient distress and suffering was most often expressed by providers in states with bans. One provider explained:

If the patient meets the criteria, including the really critical part is if they’re having distress and suffering, and if it’s causing them pain, then it’s very important to treat it. . .Not everybody wants medical treatment with hormone therapy. Most people do, not everybody, not everyone wants surgery, but if someone is suffering and having pain from lack of medical treatment, then it’s absolutely appropriate—in fact, medically necessary—to treat them.

Another clinician echoed these sentiments, but added that evidence points to success in earlier interventions if a patient meets all treatment criteria:

I’m in support of providing GAC to anybody of any age that they qualify for. There are some medical treatments that are too complicated to do for a minor, or they might be too risky to do in a minor, and those are sometimes reserved for minors that have gone through intense interview process, or young adults when they’re able to go through that process. There’s evidence to show that early intervention in appropriate environment, within the appropriate environment does produce better outcomes. So, it’s best, what we know is medical-community-wise, it’s better to intervene as early as somebody shows signs of dysphoria with GAC to prevent deterioration of mental health and prevent future comorbidities that could be long lasting and devastating for the rest of their life.

Starting GAC early, according to this provider not only helps to alleviate current distress and suffering, but also prevents youth from worse mental and physical health outcomes that can occur in when TGD individuals live with ongoing gender dysphoria.

Ethical and Moral Considerations

The central theme of personal autonomy and respect for patients’ rights emerged strongly from providers’ accounts. They consistently emphasized the importance of respecting individuals’ rights to make informed decisions about their own treatment, framing GAC as not merely beneficial but essential for achieving optimal health outcomes. This principle was most frequently highlighted in states with shield law protections (11 responses), followed by states with no legislation (10), and was less prominent in state with bans (5). One participant stated:

I believe in universal healthcare and that everyone has the right to what they need to achieve their optimal health outcomes. All of us have different health potential, but we should all have access to the care we need to achieve our best outcomes, which is kind of the definition of health equity. So, I believe in equitable healthcare for everyone, including TGD young people. And they have specific healthcare needs that are different from kids who are not TGD, and they should be able to access that care.

Relatedly, providers stressed GAC is life-saving care that reduces risk of suicide, improves mental health, and allows youth to fully participate in their lives. This belief was particularly emphasized in restrictive states, where 11 providers highlighted GAC as life-saving compared to 6 in shield law states and 5 in states with no legislation. A provider said of the GAC bans:

It’s like all of a sudden, the government outlaws chemotherapy. And we are – we can’t refer to hematologists, oncologists; we can’t provide life-saving treatment because the government is saying we can’t. It’s like that.

Additionally, providers in shield law states often noted that “children know their gender” (7 responses). This early recognition supports the importance of timely and appropriate medical intervention to support mental health and overall well-being. One provider reflected on their interactions with patients:

Almost each and every time, I’m like, “When was it that you first recognized that I am trans?” And almost always, they say since childhood or since adolescence, no matter how old they are, they are like, “Well, I’ve always known.” Can you imagine always knowing, but then fighting this tide, and then being so courageous? It’s courage that is beyond, right? I mean, we’re all scared of this or scared of that, and we have anxieties, but can you imagine saying, “All right, I’m going to live my life so authentically and so genuinely, and it starts now.”

Providers additionally noted the importance of recognizing gender as a spectrum and paying attention to the needs of individual patients (6 in restricted states, 4 and 3 in shield law states and states with no legislation, respectively). A participant shared a patient story highlighting the fluidity of gender and life-saving importance of access to GAC:

They were talking about how even though they stopped the GAC at one point, that was still part of their transition and that they recognize that that probably saved them from suicide attempts or self-harm at the time, because gender is a fluid thing and gender doesn’t have to be one or the other, and it can change as time goes on. And I think we should just allow children and teenagers the same right to make those changes as anybody else.

Professional and Personal Responsibility

Finally, many providers viewed offering GAC as a responsibility integral to their role as healthcare providers and part of their duty to patients. They frequently discussed GAC as being like all other forms of treatment in which they offer options in an objective manner and ultimately leave the decision up to patients. This perspective was most prevalent among providers practicing in states with shield law protections, where 8 responses emphasized the importance of medical judgment in decision-making compared to 6 in states with bans. One provider reflected upon a formative experience:

I remember very early on giving a talk to some local psychiatrists, child and adolescent psychiatrists and having one of the psychiatrists ask me if I approved of what my patients were doing. And I was really taken aback because I don’t even have that frame. I mean, I guess I approve, but that’s really not the lens through which I think about this. My approval or disapproval has no bearing on their lived experience.

Participants also described the provision of GAC as part of their medical judgment. Criteria for treatment, ethical considerations, and professional responsibility all inform how providers make decisions with their patients.

Along with their professional obligation to their patients, many clinicians stressed a personal responsibility that comes with treating a vulnerable patient population. A participant described their experience:

But I’ve grown more personally, and [I’m] passionate and emotional about [GAC] as I’ve met with transgender teenagers in my community through some advocacy work we’ve done together who’ve shared their mental health challenges. They’ve shared about their suicidality, a lot of which has just been rooted in not being accepted and not feeling like themselves in their own body. And so, I think I’ve grown more impassioned about the need for everyone to be able to appreciate their experiences and to offer this care because I know that it does save lives. And every time we lose a student who’s trans in our community to suicide, we lost one a couple of weeks ago, I wonder what more could be done. And I know clinicians are just one factor in their social network but can be quite influential.

Limitations

There are limitations to this study, including the possibility of investigator bias during the interview and analysis process. Another possible limitation is that a large percentage of the providers interviewed identify as cisgender women. While this does seem reflective of the demographics of GAC providers, it could bias the results.