Introduction

As partisanship deepens in American politics, establishing sharp contrasts in policy stances and electing counterproductive administrations, the future of LGBTQ+ rights remains uncertain. In the current state of affairs, one of the most contested issues associated with the queer community is access to healthcare services, particularly gender-affirming care, especially for youth. Gender-affirming care includes an array of medical, mental health, and surgical interventions that assist individuals as they align their bodies with their gender identity—services that are a point of controversy among members of both present parties. As such, recent legislation has restricted access to these services, marking the first discriminatory laws targeting LGBTQ+ individuals in two decades [1]. This trend, as monumental as it is on its own, is only expected to intensify with the current federal administration.  

Despite recent legislative setbacks, achieving true healthcare equity for LGBTQ+ individuals seeking gender-affirming care is more complex than mere access alone. Rather, full equity entails unconditional patient autonomy in making decisions about one’s care, removing systemic barriers that limit one’s access, and fostering a supportive, informed social environment for one’s affirming process. Such considerations are essential for shaping policy solutions that seek to improve medical accessibility for the LGBTQ+ community to truly enhance one’s healthcare experience and ensure their physical and mental well-being.  

Historical Overview of LGBTQ+ Healthcare

As contentious as gender-affirming care remains, these services have a deep history in the U.S., beginning in the 1940s with the work of Dr. Harry Benjamin [2]. As a pioneer in the treatment of transgender patients, Benjamin introduced groundbreaking techniques in gender-affirming care, like hormone therapy [2]. In the 1960s, access expanded with the efforts of Dr. Milton Edgerton at Johns Hopkins, who formed the U.S.’s first gender-affirming clinic [3]. However, as the LGBTQ+ rights movement gained traction in the 1970s, the public increasingly scrutinized queer rights, including healthcare access—leading to the closure of numerous, life-saving gender-affirming clinics [4].

Over time, the negative framing of gender-affirming care prompted legislative restrictions, which were further influenced by misunderstandings of the AIDS epidemic. In the 1980s, the Department of Health deemed gender-affirming care “experimental,” causing it to be excluded from federal insurance coverage, with private insurers following suit [4]. Despite these setbacks, LGBTQ+ advocates worked tirelessly to expand access and destigmatize services. 

Their devotion led to legislative success in the late 2000s, when, for instance, the Obama Administration banned denial of insurance coverage based on gender identity, allowing access for many [5]. Following these expansions, a new dimension emerged in gender-affirming care: treatment for youth, as the percentage under 18 seeking these services grew exponentially [6]. In recent years, however, progress in transitionary care has regressed; a surge in legislation restricting services, particularly for minors, challenges LGBTQ+ healthcare.

Current Threats to Services and Surgeries

Over the past few years, a wave of legal barriers has taken hold, restricting LGBTQ+ healthcare, particularly youth gender-affirming care. Nonetheless, many of these efforts have been expanded to include restrictions on adult populations. This recent trend in restrictions began in 2021, when Arkansas banned transitioning services for youth [7]. Since then, 24 additional states have adopted similar bans, with some prohibiting services up to the age of 25 [7].

In these last months, even more direct federal restrictions have passed, further destabilizing LGBTQ+ services. At the end of his term, President Biden signed the National Defense Authorization Act (NDAA) of 2025, which included a provision banning coverage of transgender services for military dependents federally [8]. Similarly, in his first months in office, President Trump issued the executive order Protecting Children From Chemical and Surgical Mutilation, which defunds institutions providing gender-affirming services to youth [9]. 

While these efforts target children, they ultimately undermine access to care for all LGBTQ+ individuals by disrupting the broader healthcare infrastructure and fostering a climate of injustice and uncertainty, which impacts one’s ability to transition. Likewise, given President Trump’s agenda to further restrict LGBTQ+, and especially transgender, rights, the question of whether individuals may receive gender-affirming care remains uncertain. However, true healthcare equity for the LGBTQ+ community extends beyond access to services. An equitable medical experience for those seeking gender-affirming care demands unconditional patient choice about one’s care, ensuring individuals can pursue access without issues, and modifying social environments to support individuals’ transitions.

Emphasizing Unconditional Patient Choice

A key aspect of an equitable medical experience for those seeking gender-affirming care is the traditional medical concept of patient autonomy. According to the American Medical Association (AMA), patient autonomy is the idea that patients “have the right to make decisions regarding their care,” meaning providers must “respect patients’ autonomy by giving them the information needed to understand the risks and benefits” of their procedures such “that they may make independent decisions” [10].  This principle directly applies to gender-affirming care, where transgender individuals seeking services should have the full right to make decisions regarding their bodies without undue influence from any medical professional. For this standard to be upheld, clinicians must actively engage in discussion about, and thus acknowledge, gender-affirming services, normalizing it as a considerable option in a patient’s journey to guarantee individuals can make a truly autonomous and informed decision.

Aside from disclosing gender-affirming services, the provision of gender-affirming care itself should tailor to each person’s needs rather than be shaped by underlying stereotypes. Given gender-affirming procedures tend to be inherently aesthetic, clinicians must approach treatment discussions without bias, ensuring interventions align with the patient’s desires rather than normative gender-binary expectations—especially for non-binary patients. Protecting patient autonomy in any context means shielding individuals from any external pressures, whether that be the expectations or influence of society, the government, one’s family, or even a partner.

Not only does full patient autonomy empower individuals to make decisions on their own terms, but it also allows them to process their experiences independently, leading to greater satisfaction with their transitionary care. By prioritizing autonomy, the medical field can create a more equitable healthcare experience for a group with a past of healthcare disparity, highlighting the complexity of achieving true healthcare equality for the LGBTQ+ community.

Removing Structural Healthcare Barriers 

Beyond providing patients with the knowledge and experience necessary for a smooth transition, achieving LGBTQ+ healthcare equity requires addressing and removing structural barriers that inhibit access to care. Structural barriers encompass a broad range of challenges, from explicit policies and facility-based practices to social trends that disadvantage specific groups. Many of these obstacles often go unnoticed, as they are embedded within institutional frameworks that were not originally designed to accommodate the needs of this community.  

At a facility-based level, structural barriers involve the functioning and inclusivity of healthcare institutions for transgender and non-binary patients. For instance, while a practice may offer transition-related services, equity in this setting requires implementing gender-neutral bathrooms, encouraging use of pronouns, employing inclusive gender identification on patient forms, and ensuring staff receive adequate training. With these practice changes, LGBTQ+ patients can feel more welcomed and trust the medical spaces they are accessing. 

Systemically, a significant structural barrier is insurance coverage for transitional services. With time, gender-affirming care has been recognized as medically necessary, reducing some barriers. However, many insurance companies have limited in-network providers, often with practitioners capable of performing procedures but not necessarily specializing in gender-affirming care, like plastic surgeons [11]. True healthcare equity ensures individuals can choose a provider they feel fully comfortable with—just as any cisgender person would if seeking medical care.  

Beyond insurance, transgender and non-binary patients also have to endure socially ingrained structural barriers that limit their access to any form of medical treatment. For instance, statistically speaking, this population experiences higher unemployment rates—nearly double that of cisgender individuals [12]. As a result, those seeking transition-related care are less likely to afford medical treatment or secure employment that provides insurance for their procedures.  

In accumulation, from the structural challenges of facility-based policies to broader socioeconomic inequalities, it is evident that achieving true equity in LGBTQ+ healthcare extends beyond mere access to gender-affirming services. Access to these life-saving treatments alone does not ensure that individuals receive the same quality of care as the general population, nor does it guarantee that they can fully utilize legally available services.

Establishing Social Environment Support

A final dimension ensuring equity in the LGBTQ+ community’s access to healthcare is the overarching social context in which individuals seeking gender-affirming care are situated. Creating a fully equitable experience entails fostering an environment that provides support for individuals during their transitioning periods. Often, gender-affirming care is seen as a simple choice; in actuality, the process is often enduring and non-linear due to physical restrictions that often leave individuals frustrated or apathetic, and more at risk for various mental health conditions [13]. Recognizing this, individuals seeking these healthcare services require additional, communal support to ensure they can access and continue to utilize treatment.  

This sensitivity and support first come through addressing social stigmatization and misconceptions about gender-affirming care through education. By informing community members about these practices and how they improve individuals’ lives and health, it empowers those of the LGBTQ+ community, encouraging them to turn to these services.  

Beyond that, this expanded comprehension involves recognizing the differences that almost always occur in gender-affirming treatment plans—each person’s journey varies in intended outcomes and procedures, based on one’s own gender expression and identity. Informing and guiding today’s communities with this perspective helps reduce social pressures from transitioning patients to conform to socially preferred notions of gender, aligning with the importance of patient autonomy and allowing the patient to guide their medical decisions.

This increased awareness towards gender-affirming care applies to all social systems in which cisgender and transgender individuals seeking care engage, from their homes to workplaces and schools. These interactions shape the beliefs individuals hold about their healthcare decisions. Interactions must be structured to uplift members of the queer community, ensuring one can obtain medically necessary, life-saving treatments without fear of judgment—reinforcing that access to these services is not enough to achieve healthcare equity.  

Future Considerations in a Time of Uncertainty

As the nation braces for uncertainty regarding LGBTQ+ rights and faces the potential for further restrictions on gender-affirming care, the true meaning of healthcare equity must remain in focus. Creating access to hormone treatment or a surgery is not enough to provide equal medical experiences for members of the queer community. It is also necessary to shape institutions that prioritize individual choice, remove barriers beyond legislation that hinder access to care, and foster a social environment that supports and encourages personal journeys.

Policy solutions aiming to protect access must consider these broader dimensions; true progress in healthcare equity requires reform beyond combating administrative restrictions. Neglecting these considerations diminishes access to life-saving, medically necessary care over time—compromising the health of an already vulnerable, historically disadvantaged population. At the same time, there is a promising aspect to these dimensions. While federal actions may seek to restrict access to care, individuals and communities at the local level have the power to implement change by addressing these other aspects. By driving reforms that support individuals in these ways, healthcare equity can be actively pursued and established.