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Legislative restrictions on gender-affirming care (GAC) for minors have rapidly expanded across the United States. Indiana Senate Enrolled Act 480 (SEA 480, 2023) prohibits gender-diverse youth (GDY) under age 18 from receiving GAC prescriptions even if they were already taking them. While prior research links state-level anti-transgender policies to adverse mental health outcomes, most studies rely on cross-state comparisons or cross-sectional designs. No study has examined longitudinal mental health changes among GDY already receiving GAC under active GAC restrictions. This study examined within-person changes in depressive and anxiety symptoms across SEA 480 policy periods and assessed whether baseline family support moderated these associations.
Methods
This longitudinal panel study included up to seven waves of data from 51 GDY (mean age = 15.2, SD = 1.7) receiving GAC at a multidisciplinary clinic in Indiana between 2022 and 2026, with 341 observations. SEA 480 was treated as a natural policy exposure with three periods: pre-passage (before April 5, 2023), injunction period (April 5, 2023- February 26, 2024), and enforcement (February 27, 2024 onward), with enforcement as the reference category. Depressive and anxiety symptoms were measured using PROMIS Pediatric Short Forms. Baseline family support (MSPSS-Family; PAGES-Y Acceptance) was tested as a moderator of the association between policy period and mental health outcomes. Linear mixed-effects models with random intercepts were estimated to examine within-person changes across policy periods.
Results
Moderation analyses revealed that family support significantly buffered mental health outcomes during the enforcement period: higher MSPSS-Family scores predicted lower depression (b = −0.336, p = .008) and anxiety (b = −0.312, p = .005), as did higher PAGES-Y Acceptance scores (depression: b = −0.358, p = .013; anxiety: b = −0.354, p = .004). Interaction terms between family support and the pre-passage and injunction periods were not statistically significant, suggesting that the protective effect of family support was consistent across all three policy periods. Policy period was not significantly associated with depressive or anxiety symptoms across all models.
Conclusions
Although policy period was not significantly associated with worsening mental health symptoms in this sample, family support was linked to better mental health outcomes. These results underscore the protective role of family support and acceptance for GDY in restrictive policy contexts. They further indicate that social workers should prioritize building and strengthening family support networks for GDY, particularly in restrictive policy contexts. Future research should examine how sustained exposure to anti-transgender policy environments, beyond discrete legislative events, shapes long-term mental health trajectories among GDY.