Ethics Alive! Urgent Alert—Some States Have Banned Gender-Affirming Care for Transgender Minors. What Are Social Workers’ Responsibilities?

by Allan Barsky, PhD, JD, MSW

     The Urgency of the Situation: Florida, Georgia, Texas, North Dakota, Arizona, and other states have recently banned or restricted various forms of gender-affirming health care with transgender people. (Toward the end of this article, there is a glossary of key terms from this article.) These laws vary from state to state, so it is important to understand the particulars of the laws where you practice (see Human Rights Campaign’s map on gender-affirming care by state). Some laws focus on care to minors (people under 18 years old), providing outright bans on surgical and medicine-based treatments, including puberty (hormone) blockers. These laws may even prohibit minors from continuing to receive treatments that they have already started to receive, meaning that they may be forced to detransition or move to another state where they can access needed medications. Some laws restrict access for adults as well as to minors, for instance, limiting or barring insurance from paying for such services. Florida’s laws also bar licensed nurse practitioners from prescribing hormone treatments, even though they had previously been responsible for treating the majority of people needing such treatments.

Relevant Ethical Principles: Access to Services, Self-Determination, Beneficence, and Protection of Life

     You may be asking yourself, “What do these laws have to do with me? I don’t specialize in services for transgender people, and, as a social worker, I am not able to prescribe medication or surgery.” Social workers, however, play incredibly important roles as advocates for access to services and as frontline workers in the fields of mental health, school-based social work, community engagement, and many other areas of practice where transgender youth may be affected. When a client walks into your office or meets with you online, you may not know in advance whether they or a family member are transgender, and whether they may need your assistance as a result of issues related to these bans on access. Even if you live in a state where gender-affirming care is openly permitted, you may have someone from another state reach out for assistance because they need out-of-state care. They may also need assistance with moving to another state where they can safely access the help they need.

     With a rise in anti-trans rhetoric and violence in the United States, more trans youth and adults may be experiencing harassment, distress, depression, and suicidal ideation. At the same time, they may find it hard to reach out to teachers, family members, social workers, and mental health professionals for help, fearing gender-based biases, lack of empathy, or refusal to provide appropriate services. We need to be proactive. Lives are at risk.

     Under the National Association of Social Workers Code of Ethics (2021), social workers have a responsibility to promote access to needed services. For transgender people with gender dysphoria (a mental health condition marked by distress resulting from having one’s gender identity not match their sex assigned at birth), age-appropriate gender-affirming care is a medically necessary, effective, and safe form of service. The American Medical Association, the American Academy of Pediatrics, the National Association of Social Workers, the American Psychological Association, the World Medical Association, and many other well-respected national and international health associations all have statements in support of evidence-based gender-affirming care.

     The NASW Code of Ethics, Standard 1.02, highlights the duty of social workers to promote client self-determination. This standard includes the right of transgender people to determine what types of medical care, mental health services, and ancillary services they need or desire. Standard 1.03 suggests that parents, guardians, or other adults with parental rights are responsible for making decisions for minors. Social workers can act as advocates to promote the rights of patients and family decision makers, including the rights to access gender-affirming care. Similar to other helping professions, social work believes in beneficence (doing good) and protection of life. Together, these ethical principles highlight the need for social workers to facilitate access to services for minors and adults who need gender-affirming care.

How Should We Manage Conflicts Between Laws and Ethical Obligations?

     You may be wondering what you can do to ensure access to gender-affirming care if it seems that doing so is against the law. Here are some points to consider:

1. Learn what your state laws specifically prohibit and allow. For specific questions requiring legal advice, you or your agency may need to consult an attorney. For basic information, your state NASW chapter or state chapters of APA, AMA, and other organizations may have information. Accessing current and accurate information from governmental websites with statutes can be complex. Even if you find the right statute and section, the section may be difficult to interpret, there may be additional regulations elsewhere, and the law may be under review by the courts. Some states have already had judgments that imposed injunctions on laws attempting to ban or restrict gender-affirming care. Hopefully, professional liability insurance companies will soon come out with guidance for practitioners. We cannot afford to lose good social workers who could be providing services to people in need because they have received misinformation about what they are prohibited or permitted to do in practice with transgender people.
2. Continue to serve transgender youth and family members. Note that even a ban on gender-affirming care does not mean that we are prohibited from serving transgender youth and family members. The restrictions are typically related to surgery and medication treatments, not talk therapies or supportive counseling and groups. Many services that you may have offered to transgender clients in the past continue to be legal and clinically important. The simple act of providing transgender people with a safe, empathic place to discuss their concerns can be vital to their mental health and well-being. Legal risks are associated with contravening specific criminal or regulatory laws. For instance, there are legal risks associated with “aiding and abetting” a crime: if a social worker referred a client to an unlicensed provider of puberty blockers or hormone treatments, this could incur criminal liability. Helping a transgender person or family members with issues related to managing anxiety or other emotions, dealing with harassment or discrimination, and discussing options for social transitioning would not be covered by laws that prohibit surgery and medication. Again, please consult an attorney if you have specific questions related to your state’s laws and risks of particular courses of action.
3. Raise awareness of these concerns. You may have professional colleagues, friends, associates, or clients who are unaware of the bans on gender-affirming care or their implications for transgender clients, their families, professional service providers, and social support networks. Consider hosting educational meetings in your agencies, in schools, or online, perhaps with agencies specializing in services to transgender youth. Encourage coordination between social work and other health/mental health associations that may be affected (nationally and statewide)
4. Seek out continuing education on working with transgender people. If you do not have training and experience in working with transgender people, consider engaging in relevant and current trainings. Given the anti-trans sentiment in some states, there may be some state licensing boards that do not accept certain continuing education (CE) courses related to working with transgender people. There may be a need for education and advocacy about what types of courses should be approved for CEs. Remember, even if a course is not approved for CEs, it may be important and useful to take it—unfortunately, you may be prohibited from counting it toward licensure requirements for CEs.
5. Collaborate with advocacy organizations and service providers. Consider working with equality rights organizations such as American Civil Liberties Union, National Center for Lesbian Rights, Human Rights Campaign, and Transgender Legal Defense and Education, as well as local and regional transgender and LGBTQ+ community centers and service providers. They can also provide you with updates on their participation in legislative advocacy, public education, legal challenges, precedent-setting cases, and current injunctions, if any.

     Some situations may raise challenging ethical dilemmas—for instance, if you learn of a client who is purchasing hormones online because they cannot obtain them legally within their state. In addition to the legal risks, there are risks of taking drugs from unreliable sources and from not having the support of a proper medical team. For challenging dilemmas, consult with clinical experts, ethics consultants, or legal counsel as needed. Refer to the NASW Code of Ethics and relevant laws in your state. Strive to work collaboratively with your clients and develop win-win solutions. Use your best conflict resolution skills. Document, document, document—information you gathered, who you consulted, options you considered, the decision you reached, how you reached it, and how you implemented it.

     Helping transgender clients in these times does not necessarily entail significant legal risks or challenging ethical issues. We have people in need and laws that may make service provision more challenging. Support is available. Social workers embrace challenges and find opportunities to help.

Quick Guide to Key Terms Related to Gender-Affirming Care

Transgender Person: Someone whose gender identity does not match the sex assigned at birth. This term has different definitions and may include people who identify as men, women, genderqueer, gender nonbinary, gender fluid, gender diverse, two-spirit, or other gender identities. Although some people who are transgender have gender dysphoria, others do not. Also, note that gender identification should not be equated to sexual orientation.

Gender-Affirming Care: Any type of supportive care for a person who identifies as transgender or has concerns related to their gender being different from their sex assigned at birth. Although gender-affirming care may include medication and gender-affirming surgery, it may also include individual, family, or group counseling; legal assistance; mental health services: and social services.

Transitioning: Process of making changes in one’s life to create a better alignment with their gender identity. Transitioning is a different process for each person, including what steps they take, in what order, and along what timeline. Possible steps include: disclosing their gender identity to friends, family, employers, or others; changing name and pronouns; changing legal documents to match name and gender identity; wearing different clothes and hair styles; participating in support groups; being assessed by mental health professionals to help develop an appropriate transition plan; engaging in speech therapy; and medical interventions such as hormone therapy or surgical intervention, often called gender confirmation surgery.

Detransitioning: The process of reversing one or more of the processes of transitioning described above. Although many processes of detransitioning are not medically risky, being suddenly forced to detransition medically because the state bars access to puberty blockers or hormones can lead to significant physical and psychological risks.

     For further information about gender-affirming care, please see https://www.hrc.org/resources/get-the-facts-on-gender-affirming-care. Detailed standards of care for the health of transgender and gender diverse people are available at: https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644

Acknowledgements: Thank you to Dr. David Landsman-Wolsifer, PhD, LCSW, for sharing his insights, recommendations, and practice-based suggestions for this article. Thank you also to the courageous transgender youth and advocates in Tallahassee, Florida, who helped educate me about these issues and their impacts as the laws related to gender-affirming care were debated during the 2023 legislative session.

Allan Barsky, PhD, JD, MSW, is Professor of Social Work at Florida Atlantic University and author of  Social Work Values and Ethics (Oxford University Press).

The views expressed in this article do not necessarily represent the views of any of the organizations to which the author is affiliated, or the views of  The New Social Worker magazine or White Hat Communications.