Gender-Affirming Care Restrictions Create Travel, Care Access Barriers

July 27, 2023 - The travel distances that gender-affirming care restrictions, now codified in many state policies, have created are getting insurmountable, with a new analysis in JAMA showing some people must travel up to 8.5 hours away from their homes to receive care.

Gender-affirming care has been endorsed by leading medical societies like the American Academy of Pediatrics and the American Medical Association. Gender-affirming care is medically necessary and evidence-based, both organizations have long stated.

But restrictions on gender-affirming care continue to crop up at the state level. The study authors, who hailed from the University of Michigan Medical School, said that a total of 20 states had enacted legislation, executive actions, or other policies restricting youth access to gender-affirming care as of May 2023. On top of that, there are over 100 bills restricting gender-affirming care that are currently under consideration, the researchers said.

Those restrictions are leaving kids and their families in some states having to travel to other states where gender-affirming care is more accessible.

And those travel distances are getting exorbitant, the researchers said.

The researchers identified clinics that advertise access to gender-affirming care to transgender individuals under age 18 and used US Census data to calculate travel distances to the nearest clinic when there was no traffic. The team compared travel times to the nearest clinic before and after restrictions became common.

As a result of state-level restrictions on youth access to gender-affirming care, nearly a quarter of the gender clinics in operation had to close down. Around 30 percent of transgender youths in the US live in a state with restricted access to gender-affirming care, representing 89,100 kids.

And because those children don’t have anywhere to go in their states to receive gender-affirming care, they have to travel elsewhere, resulting in greater travel distances.

The median drive time before restrictions were put in place was around a half hour, but after those restrictions, travel time nearly doubled to around an hour. Half of US kids ages 10 to 17 live more than an hour from a clinic offering gender-affirming care. That’s compared to only 27 percent of youths who lived that far away prior to restrictions.

For some kids, the travel times are exorbitant and prohibitive.

Prior to state-level restrictions on gender-affirming care, less than 2 percent of kids lived more than a one-day drive (defined as eight hours of total drive time, or four hours one way). But today, 25 percent of kids face that long of a travel distance.

Increases in travel time to gender clinics were extreme in Florida (an increase of 8.5 hours), Texas (an increase of 6.7 hours), and Utah (an increase of 5 hours).

The study did not look into how many kids did not access gender-affirming care due to these travel distances, but the researchers did indicate that this could be a problem.

“Increased costs and time burdens of travel may further contribute to delayed treatment, inability to access care, and worse mental health for transgender youths,” they said.

“With more than 1 in 4 gender clinics located in states with restrictions, it is unknown whether existing clinics may have capacity to meet the increased need of out-of-state patients,” they added in reference to gender clinics that would be able to stay open.

There is some precedent for how travel distances affect care access. In rural areas, it is conventional wisdom that patients go without as much healthcare in part because they have to travel in order to see a provider. That is why some policymakers have promoted telehealth and broadband access in these areas.

There has also been some research into how restrictions on other types of care, like abortion, have created extreme travel distances that prohibit care access. In 2022, researchers wrote in JAMA Network Open that the further a patient lived from an abortion clinic, the more care access barriers they faced. Barriers included getting time off work and having enough money for travel expenses.

While policies restricting abortion are different from policies restricting youth access to gender-affirming care, that data could indicate how travel distances affect care access.