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This study examined how U.S. gender-affirming (GA) care providers have adapted their practices to support trans and gender diverse (TGD) clients while managing increased personal and professional risks amid the current wave of anti-trans policies. By understanding how providers are adapting in real time, we can remain critically conscious of how social-political threats are impacting client care and the GA workforce, and what new organizational supports may be needed to sustain changing practice norms.
Methods
Using a mixed-methods design, in the first phase of analysis, two independent coders applied a phenomenological approach to analyze qualitative responses from 124 participants. In the second phase, a hit-miss matrix was used to conduct chi-square tests for statistically significant differences in response patterns between cis and TGD providers and between providers with and without state restrictions on GA care.
Results
Participants described practice changes falling into five distinct categories: 1) increased time and energy spent navigating practice disruptions (37.3%); 2) increased support of clients’ social and emotional needs (30.0%); 3) increased security measures (18.8%); 4) increased advocacy and management of misinformation (8.8%), and 5) renewed commitment to GA care (3.1%).
The two most reported adaptations demonstrated a priority for continuity of client care. Providers reported spending more time on case management tasks and meeting with healthcare administrators and lawyers to understand laws and develop policies so clients could be transferred or received across state lines. Additionally, providers described spending more time educating, monitoring, and being present with clients experiencing increased distress over anti-trans rhetoric and restrictive policies.
Despite prioritizing care, providers also spent time, energy, and money protecting themselves. Close to a fifth of participants described changes aimed at mitigating personal and professional risk, including adding security guards, limiting public disclosures about their work, increasing legal vigilance, and altering communication about clients with other providers.
Chi-square analyses showed no statistically significant differences in practice adaptations between cis and TGD providers or between states with and without restrictions on GA care.
Conclusions and Implications
Rapidly changing policy is requiring immediate, ground-up adaptations to practice, with one provider describing it as “building the plane while flying it.” Beyond structural disruption, ambiguity regarding legal risk may influence clinical decision-making, contributing to delayed care or more conservative practices. Consequently, providers should seek consultation and cultivate peer support to manage tensions between client care and personal and professional risk.
Health systems can no longer treat legislative shifts affecting gender-affirming care as temporary disruptions managed through informal adaptations. Administrators and organizations should consider system-level innovations to prevent burnout and support shifting care demands. This may include interdisciplinary policy teams or ethics consultation mechanisms to help clinicians interpret evolving legislation and translate it into clinical guidance. Finally, integrating access to case managers and insurance specialists into routine care may improve continuity and reduce stress. Community partnerships may also help expand access to support services, particularly for smaller organizations and private providers.