Position

The American Academy of Nursing (Academy) supports equitable access to health care for all people, including access to the full spectrum of gender-affirming care. Gender-affirming care is essential for the physical and mental well-being of transgender and gender-diverse (TGD) populations. In the face of increasingly prohibitive legislation and regulations restricting access to this care, which is not in alignment with current evidence-based best practice guidelines, the Academy urges strong protections along with efforts to expand access for the full range of gender-affirming services and care.

Background

Current Landscape of Restrictions on Transgender and Gender-Diverse Health Care

The Academy has long supported the protection and promotion of policies that support the health and well-being of TGD populations.^1,2,3 This is particularly important as the narrative surrounding gender-affirming care has become more hostile, with increasing misinformation and legislative attacks on the ability for people under 18 years of age to access gender-affirming care. Prior to 2021, no state had active legislation restricting access to this care. Since 2021, 26 states have enacted laws or policies seeking to restrict access to gender-affirming care for minors and 24 of these states have imposed professional or legal penalties for health care practitioners providing this care to minors.⁴ Gender-affirming care—which is holistic, patient-centered, and inter- and multidisciplinary—is grounded in decades of research and science. The current guidelines of care for TGD populations are based on this science and the expert consensus of health care professionals.^5,6 Gender affirmation is a unique process for each individual, and not all TGD individuals will choose to transition hormonally or through surgical or other procedures. Gender-affirming health care encompasses a wide range of services, including but not limited to hormonal and surgical treatments, voice and communication therapy, primary care, reproductive and sexual health care, and mental health care.⁵ Restricting access to this medically necessary care creates significant burdens on accessing health care for the affected populations.⁷ Restrictive legislation also has a direct impact on mental health: TGD young people ages 13-17 had statistically significant increases in rates of past-year suicide attempts in states that enacted legislation restricting the rights of TGD people relative to states that did not.⁸ Furthermore, the health care providers who are unable to provide care to their patients in accordance with current guidelines and evidence face potential professional or legal penalties. Policies and legislation at all levels of government that interfere with the patient-provider relationship and provision of evidence-based care should be prohibited. Protecting and promoting access to gender-affirming care is a key priority to promote health and well-being.

The Need for Transgender and Gender-Diverse Health Promotion 

Research on TGD populations has consistently shown that these populations experience a greater burden of poor physical and mental health outcomes compared to the overall population, including a higher burden of multiple chronic conditions and disabilities.⁹ These health disparities and increased disease burden are largely rooted in societal stigma and discrimination.¹⁰ Research on the mental health of TGD populations is limited, due in part to TGD identities being inappropriately categorized in the area of mental illness until recently.¹¹ However, the literature to date clearly illustrates that TGD populations are disproportionately exposed to harmful social and structural determinants of health, including stigma and discrimination, that influence their experiences with mental health and substance use disorders. Among TGD populations, depressive symptoms, suicidality, interpersonal trauma exposure, substance use disorders, and anxiety are experienced at elevated rates compared to the overall population.^11,12 Among TGD youth in particular, an estimated 28% had a lifetime history of suicidal ideation.¹¹ To improve the health and well-being of TGD populations, protecting and expanding access to gender-affirming health care is critically important. The National Academies of Sciences, Engineering, and Medicine (NASEM)’s 2020 report on Understanding the Well-Being of LGBTQI+ Populations outlines the significant and growing body of research which shows that gender-affirming health care services improve mental health outcomes and quality of life for TGD people.¹³ Protecting and expanding access to this care aligns with scientific evidence and best practices.

Insurance Coverage and Nondiscrimination 

The 2020 NASEM report highlights that guaranteed access to health care services, health insurance coverage, and public health programs are critical to the health and well-being of sexual and gender minority populations.¹³ It is important to ensure that gender-affirming care is covered under insurance as well as ensure that networks include providers who specialize in care for TGD populations, such as advanced practice registered nurses (APRNs),¹⁴ and allow them to practice at the top of their licensure. For coverage under state Medicaid policy, around half of states (26 and the District of Columbia) explicitly cover gender-affirming health care, but many do not clearly address whether this care is covered (12 states) or explicitly exclude coverage of this care for all ages (10 states).¹⁵ A lack of clarity on coverage options can lead to confusing or difficult experiences for TGD people seeking gender-affirming care, while explicitly excluding gender-affirming care from coverage imposes significant burdens on TGD people who rely on Medicaid and therefore may not be able to access their medically necessary care at all. For private insurers, nearly half of states (24 and the District of Columbia) have policies that prohibit explicit refusal to cover gender affirming-related health care benefits.¹⁶ Other states have varying policies, and 2 states explicitly allow insurers to refuse to cover gender-affirming care.¹⁶ 

Section 1557 of the Affordable Care Act (ACA)  (42 U.S.C. 18116) prohibits discrimination on the basis of race, color, national origin, age, disability, or sex in health programs or activities that receive federal funding. In May 2024, the Nondiscrimination in Health Programs and Activities Rule reinstated the 2016 expansion of “sex” to encompass “gender identity,” codifying protections against discrimination on the basis of gender identity in covered programs and activities.^18,19 This expansion of protections is critically important to promote access to care for TGD people. However, despite this federal protection, the differences in gender-affirming care coverage across state Medicaid and private insurance policies reflect varying interpretations of this rule, including on which programs are covered and which policies would be considered sex-based discrimination.²⁰ Furthermore, several states have moved to block the implementation of the rule across the nation.¹⁹ With the legal landscape surrounding access to gender-affirming care in flux, it is critically important to affirm that prohibitive legislation and regulations are not in alignment with current evidence-based best practice guidelines. NASEM (2020) underscores that “insurance coverage of gender-affirming services and procedures by public and private payers is necessary to facilitate access to these services and to avoid discrimination on the basis of sex and gender identity.”¹³ In the face of ongoing discrimination toward individuals based on their gender identity, promoting access to gender-affirming care through protections under rules and regulations remains a high priority. 

Research Needs & Data Privacy Across Settings

The Academy has long supported the advancement of inclusive, safe, and supportive health care for TGD populations.^1,2,3 These populations are underrepresented in clinical research; social and behavioral research; chronic diseases and comorbidities research; and methods and measurement research.²¹ Additional research can help identify how to improve the quality of gender-affirming care patient interactions as well as identify interventions to improve patient experience with day-to-day management of their care. Furthermore, sexual and reproductive health for TGD populations remain understudied and a key area for continued research. Emphasizing precision health and health across the lifespan is key, as TGD people have different needs across age groups and in relation to health conditions they may experience as they age. These needs are currently not well-understood, and these identified areas of research must be prioritized. 

Expanded research efforts are needed to better equip health care providers with information to continually improve care and health outcomes with and for TGD populations. In addition to researching the aforementioned areas of overall physical and mental health inequities, there are significant gaps in research addressing educational standards for health care professionals to equip them to provide safe, supportive, and personalized care to TGD people; sexual and reproductive health care needs of TGD populations, including related to abortion care, pregnancy, and perinatal support; decision support and counseling for gender-affirming care; and precision health across the lifespan, including for older TGD adults. Improved sexual orientation and gender identity (SOGI) data collection is key to promoting and enhancing research in this area.²² While advancing research, it is essential to maintain the privacy and security of SOGI data collected, especially due to the increased monitoring and legal threats toward TGD people. In some states, the records of people who received gender-affirming care were requested to be collected from universities and hospitals, putting patient privacy at risk.^23,24 

Data privacy and security are concerns in both research and clinical settings. In clinical settings, although data privacy is protected under the Health Insurance Portability and Accountability Act (HIPAA),²⁵ HIPAA protections cannot prevent mistreatment of data within health care systems. It is critical to implement clear organizational policies to control the collection of, access to, and use of patient data.²² The HIPAA Privacy Rule has been updated several times since its adoption to better reflect current data privacy needs and best practices,²⁶ including a recent update to modify existing standards by prohibiting uses and disclosures of protected health information (PHI) for criminal, civil, or administrative investigations or proceedings against people for seeking, obtaining, providing, or facilitating lawful reproductive health care.²⁷ It has not been clarified if such protections extend to the health data of people who have received gender-affirming care. Given the ongoing threats to the security and privacy of TGD people’s health data, updates to the HIPAA Privacy Rule are needed to protect against the possibility of criminal and civil proceedings against individuals seeking, obtaining, providing, or facilitating lawful gender-affirming care. Gender-affirming care decisions directly affect people’s health and well-being and these decisions are private and personal. All people should have the ability to make health care decisions in partnership with their providers and with full knowledge that their health data will be private and secure.

Responsibilities of Nurses

Many TGD people experience significant challenges in accessing gender-affirming health care, with 17% of TGD adults reporting that they have had a health care provider refuse to provide them with gender-affirming treatment.²⁸ Additionally, many TGD adults note that they have had to teach a health care provider about TGD people to get appropriate care (31%), had a provider refuse to acknowledge their gender identity (31%), or been asked unnecessary or invasive questions about their gender identity unrelated to their visit (29%).²⁸ Nurses play a key role in educating future nurses as well as educating patients on their health care treatment options and advocating for patients’ rights, health, and safety. The spread of misinformation about gender-affirming care and the science underpinning evidence-based guidelines is deeply harmful to TGD populations’ health and well-being. While the Academy acknowledges nurses’ diverse personal beliefs and values, the moral and ethical positions of the nurse should never undermine the ability of the patient to receive timely, accessible, person-centered, and equitable quality care.

The American Nurses Association’s (ANA) Code of Ethics for Nurses is “a nonnegotiable moral standard of nursing practice for all settings.”²⁹ According to the Code of Ethics, "Recipients of care have the moral and legal right to determine what will be done with and to their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed decision; and to be assisted with weighing the benefits, burdens, and available options in their treatment, including the choice of no treatment.”."²⁹ Nurses can support people considering gender-affirming care options using effective decision support interventions such as evidence-informed patient decision aids.³⁰ The ANA affirms that “nurses have an ethical duty to honor and respect the identities, beliefs, values, and decisions of all patients.”³¹

Policy Recommendations

Gender-affirming care is medically necessary care that is essential to the physical and mental well-being of TGD populations. The Academy urges strong protections along with efforts to expand access for the full range of gender-affirming services and care.

1. Support policies and legislation at all levels of government that explicitly call for coverage and inclusion of gender-affirming health care and other protections for TGD individuals.
2. Prohibit policies and legislation at all levels of government that interfere with the patient-provider relationship. This includes legal actions that restrict access to gender-affirming care and against those who seek access to and those who provide this care.
3. Require health insurance plans (both public and private) to provide access to comprehensive gender-affirming health care under evidence-based guidelines, including coverage for medical, mental health, surgical, and non-medical services that are essential to well-being across the lifespan.
4. Ensure that provider networks include providers who specialize in care for TGD populations, including APRNs, and ensure they are able to practice at the top of their licensure.
5. Protect TGD populations from discrimination across all spheres and particularly in accessing health care by supporting the full implementation of protections as intended by Section 1557 of the ACA and the Nondiscrimination in Health Programs and Activities Rule.
6. Improve sexual orientation and gender identity (SOGI) data collection practices in alignment with recommendations from the National Academies of Sciences, Engineering, and Medicine.²²
7. Increase funding for TGD health research aimed at continually improving care and health outcomes for TGD populations. This includes research assessing training in gender-affirming care best practices for health care providers as well as research targeting the social inequities experienced by TGD populations.
8. Expand and clarify guidelines related to the privacy and security of TGD people’s health data. This includes but is not limited to expanding the HIPAA Privacy Rule to strengthen protections for TGD people’s health data against possible use and disclosure for criminal and civil proceedings against people seeking, obtaining, providing, or facilitating lawful gender-affirming care.
9. Promote adherence to the Code of Ethics for Nurses and hold nurses accountable for the spread of misinformation counter to science- and evidence-based guidelines.

This position statement originated from the Academy’s Expert Panel on LGBTQ+ Health. The Academy’s Expert Panels are the organization’s thought leadership bodies. Through the Expert Panels, Academy Fellows, with subject matter expertise in specific areas, review the current trends, research, and issues within their field to make informed and evidence-based recommendations. It was approved by the Board of Directors on October 30, 2024. Updated March 13, 2025 to reflect the 2025 ANA Code of Ethics for Nurses as outlined on page 4 of this position statement..

Citations

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14. APRNs include nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives. 
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