Gender-diverse individuals not only fear losing their access to gender-affirming care but may resort to self-harm or questionable alternatives if it disappears, according to new research from the University of Vermont (UVM) published July 16 in JAMA Network Open. 

Teresa Graziano, a professor of nursing at UVM and lead author of the study, surveyed 489 gender-diverse Americans 18 and over about their expectations for medical care after President Donald Trump campaigned on rolling back protections for the nearly two million trans, nonbinary, and intersex individuals in the United States. Gender-affirming care (GAC) includes surgical procedures, hormonal treatments, or mental health services for individuals with gender dysphoria. The findings of Graziano’s study were stark: Every respondent thought they would lose access to care, nearly a third reported they would consider some form of do-it-yourself hormone therapy, and over 21 percent expressed either active or passive suicidal ideation. 

“This is a population that already feels that their access to care is constantly under threat, and so when you have somebody going into power that is campaigning on removing their access to care they believe it,” says Graziano, a registered nurse who uses they/them pronouns. “It was startling.” 

The study closed on Inauguration Day, January 20. Since then, a series of Executive Orders has been issued preventing the U.S. government from recognizing more than two sexes—male and female—and directing federal agencies and programs to work towards banning  gender-affirming care for trans youth. Additional orders include proposals to prohibit gender-affirming care as an essential benefit for patients on health insurance plans offered under the Affordable Care Act. However, those orders are currently tied up in the courts. In June, the Supreme Court upheld Tennessee’s ban on gender-affirming care for minors, opening the door for other states to do the same. 

“I want be clear that there is no federal ban on care right now,” Graziano says, adding that most providers are still caring for patients. 

Graziano’s research aims to improve outcomes and patient care for gender diverse populations—groups that historically have higher rates of suicide, anxiety, and depression than the general population. As they combed the data, Graziano became concerned at the terms people were using when asked what, if anything, they would do if gender-affirming care was banned. While some participants talked about suicide, others spoke more passively about it. 

“They are saying that there is not a life worth living without being their authentic self,” Graziano says. 

They point to the real dangers that persist if access to gender-affirming care is denied. People may turn to extreme measures such as using do-it-yourself hormone therapy that can jeopardize their health. 

“This can quite literally be people's synthesizing hormones at home using kits that you can purchase online,” Graziano says. “It may also be the use of the gray or black market especially for things like testosterone which are FDA regulated and are controlled substances.” 

Patients on hormones require careful blood monitoring to ensure they are taking the proper dosage. Osteoporosis can develop when hormone levels are outside normal levels, Graziano explains. 

A ban on gender-affirming care could damage the trust between patients and their healthcare providers. If patients acquire hormones through questionable means, they may not trust their doctors enough to admit it. 

“The hope is that yes, they [will] because medicine and the legal system has been very good about keeping it fairly separate when things like that happen,” Graziano says. 

Should a ban on gender-affirming care come into effect, Graziano advocates that clinicians treat gender-diverse individuals using a harm reduction approach—a practice generally used for individuals with substance abuse disorders. 

“We should not be judging this community for making do with what they have,” Graziano says. “We just need to partner with them to make sure they are as healthy as possible as they get through what they need to get through. And I think that as we continue having these conversations about whether or not this care should be banned, we also need to think about how this is going to affect the lives of very real human beings whose mental health is reliant upon their access to being their true self.”