SB 254’s Impact on Trans Floridians

FLORIDA HRT CRISIS: S.B. 254, effective May 17, 2023, disrupted nearly all HRT prescriptions for trans adults — with no end in sight.

It’s been 7 months.

What did SB 254 prohibit?

  • Prescribers other than MDs and DOs are prohibited from prescribing gender-affirming hormone therapy to adults, and cannot write new prescriptions or renewals of existing prescriptions. An estimated 80% of trans adults in Florida were prescribed HRT from an NP.
  • SB 254 requires that MDs and DOs obtain in-person written informed consent from adult trans patients before initiating gender-affirming treatment, and specifies that this initial consent must be obtained using forms approved by the Florida Board of Medicine and Board of Osteopathic Medicine. These forms contain a number of incorrect medical statements and confusing information.
  • Trans adults in Florida cannot start gender-affirming treatment via a telehealth provider. Because SB 254 specifies that informed consent must be obtained in-person before starting HRT, adults in Florida wishing to start gender-affirming treatment cannot receive their initial prescription via a telehealth appointment.

“This law has got to be completely reversed. The science is on our side.”

—Joey Knoll, CEO and nurse practitioner at SPEKTRUM Health

Read more: How providers are navigating Florida’s new law restricting access to gender-affirming care

How you can help:

Donate to SPEKTRUM Health’s
Patient Assistance Fund

SPEKTRUM Health is a nurse practitioner-led clinic in Orlando and Melbourne providing gender-affirming primary care, mental health services, and assessment and referral for gender concerns. SPEKTRUM is a nonprofit and all donations are allocated directly to clinic operations and care for patients.

Donate to Southern Legal Counsel
SLC’s Simone Chriss (she/her) is a grand marshal at Come Out With Pride Orlando 2023!

Southern Legal Counsel is a Florida nonprofit leading the legal challenges against SB 254’s trans youth care ban and trans adult care restrictions in the ongoing Doe v. Ladapo case. SLC helped win the Dekker v. Weida Medicaid exclusion case for trans Floridians.

What happens next? Upcoming trial dates and class action certification in Doe v. Ladapo (updated October 21)

  • On September 11, the court in Doe v. Ladapo denied plaintiffs’ motion for a preliminary injunction against SB 254’s restrictions on adult care (ECF no. 151). This means these restrictions are still in force and still affecting trans people and our gender-affirming care providers throughout the state.
  • On October 18, the court granted plaintiffs’ motion for class certification (ECF no. 166). The order certified “all transgender adults in Florida who seek gender-affirming treatment” and “all transgender minors in Florida who seek gender-affirming treatment” as classes in the lawsuit. If the court should ultimately rule in favor of the plaintiffs, this ensures that such a ruling would protect all trans people in Florida seeking gender-affirming care, without limiting this relief to the named plaintiffs in the case.
  • The trial is now scheduled to take place on December 13-14 and December 20-22 (ECF no. 196).

Trans adult population by state. Number 1: California, 150,100 trans adults. 2: Florida, 94,900. 3: Texas, 92,900. New York: 81,800. Source: Williams Institute June 2022 trans population estimates for California, Florida, Texas, and New York, ages 18+.

Trans care bans were never about “protecting children” — they were about making all trans existence completely impossible.

Genocide by attrition occurs when a group is stripped of its human rights, political, civil and economic. This leads to deprivation of conditions essential for maintaining health, thereby producing mass death. … Unlike genocide executed primarily by murder, genocide by attrition decimates group members by several methods, including creating conditions undermining physical and mental health that regularly result in death of part of the group and demoralization and atomization of the remainder.”

Helen Fein, executive director of the Institute for the Study of Genocide at the John Jay College of Criminal Justice (Fein, 1997)

“The policies of the DeSantis administration are going to kill people, and there’s not really a good reason to call it something that it isn’t. When you take away the very things people need to survive, people die. What is happening in Florida is so far down the path of full-scale eradication of human beings, it’s terrifying to imagine what would need to happen next for people to react accordingly.”

—Jessica Kant, LICSW MPH at Boston University School of Social Work

There’s no appropriate way to do that because it’s medically necessary treatment. The premise is flawed. … You can harm someone at whatever pace you want, but you’re still harming them.

—Alex Keuroghlian, MD MPH, associate professor of psychiatry at Harvard Medical School (STAT News, May 26, 2023)

“Florida’s interlocking policies are, at this point, explicitly genocidal. These policies will kill people. Folks can’t get their hormones. They need those. Don’t look away or abandon Floridians.”

—Quinnehtukqut McLamore PhD, conflict psychologist, University of Missouri at Columbia

How could this happen? It started when Florida hired a Gainesville hate group to help ghostwrite the state’s anti-trans policies.

Last August, Florida’s Agency for Health Care Administration (AHCA) enacted Rule 59G-1.050(7) and excluded all treatment for gender dysphoria from state Medicaid coverage, including puberty pausers, gender-affirming hormone therapy, and gender-affirming surgeries. This rule, as well as the Florida Boards of Medicine’s March 2023 bans on trans youth care, were supported by the AHCA’s June 2022 Generally Accepted Professional Medical Standards (GAPMS) report, an anti-trans policy document unlike any other to date.

“The state’s attack on access to care for trans folks in Florida all started with this rule being promulgated by the Agency for Healthcare Administration (AHCA) which began on April 20, 2022. After AHCA determined that treatments for gender dysphoria were ‘experimental,’ that justification was relied upon by the Florida Boards of Medicine in promulgating their rules banning care for minors, and that same justification was also relied upon by the legislature in passing SB 254.

—Simone Chriss, director of Transgender Rights Initiative, Southern Legal Counsel

This report was written by “experts” hired from outside the agency, working at the anti-LGBTQ hate group American College of Pediatricians (ACPeds) in Gainesville, Florida – a fringe conservative religious group with 700 or fewer active members, not to be confused with the mainstream American Academy of Pediatrics (AAP) which has over 67,000 members.

The American College of Pediatricians supports anti-LGBTQ conversion therapy and is closely tied to the conversion therapy group National Association for Research and Therapy of Homosexuality (NARTH). ACPeds opposes marriage equality, LGBTQ parenting and adoption, all gender-affirming treatments and social transition, birth control, no-fault divorce, and abortion in all circumstances. In fact, this hate group has declared itself the enemy of most Americans and our country’s most important and cherished institutions:

Threats to the College include the Southern Poverty Law Center (SPLC), the Human Rights Campaign (HRC), and the LGBTQ lobbying body, as well as mainstream medicine, psychology, academia, media, corporate America and nominal Christians, churches and organizations.”

—American College of Pediatricians, 2017 board meeting minutes (, Doctors Behind Mifepristone Ban Called ‘Christians’ a Top Threat)

ACPeds leaders, committee members, and affiliates – including Quentin Van Meter, Andre Van Mol, and Michelle Cretella – were extensively consulted in crafting the Medicaid exclusion, providing “expert reports” and other materials intended to evaluate whether gender-affirming care should be covered. Internal documents from AHCA during the development of these reports even included dozens of pages of material apparently copied by Andre Van Mol from an earlier American College of Pediatricians internal document.

There’s one more problem: Quentin Van Meter, himself president of ACPeds, had already declared in court in November 2021 that their members all hold a fixed and unalterable commitment against “[s]aying in their professional opinions that these gender intervention procedures are the standard of care, are safe, are beneficial, are not experimental, or should otherwise be recommended”.

So how could this private religious organization develop an objective and evenhanded evaluation of evidence on gender-affirming treatment for a state agency, if they already knew the conclusion they always reach?

It turns out that wasn’t a problem at all for the governor’s office, the Florida Department of Health, state surgeon general Joseph Ladapo, or AHCA: documents revealed in court filings show that these agencies had already met in April and had even prepared a “policy pathway” that would end in “Care Effectively Banned”.

As a result of this and other extraordinary acts of bad faith, the Medicaid coverage exclusion was overturned in Dekker v. Weida.

It wasn’t the first time.

Leaders of ACPeds had previously been commissioned by the anti-LGBTQ conservative legal group Alliance Defending Freedom (ADF) to “refute” our internationally accepted treatment standards, the WPATH Standards of Care (SOC). The ADF offered $10,000-15,000 to ACPeds, including Quentin Van Meter and Michelle Cretella, to produce a rebuttal of the SOC “for use in litigation”, noting that this “should also benefit many other allies at State and Federal Level”.

Cretella had previously described herself and Van Meter as “devout Catholics with a knowledge of and respect for the natural law”, declaring their religious intolerance of all LGBTQ youth and of the Enlightenment itself:

“Make no mistake that the non-heterosexualizing and transgendering of children is a grave evil with no basis in science. … This is the inevitable culmination of the hubris which gave birth to the Enlightenment; the hubris that claimed we could replace God with human reason alone and keep both objective science and morality intact. Theology is the Queen of the sciences…”

Michelle Cretella, executive director of the American College of Pediatricians

(A quick refresher: the Enlightenment age introduced “a range of ideas centered on the value of human happiness, the pursuit of knowledge obtained by means of reason and the evidence of the senses, and ideals such as natural law, liberty, progress, toleration, fraternity, constitutional government, and separation of church and state.“)

Working backward from their desired legal arguments, the ADF even asked ACPeds to find evidence for a number of blatant falsehoods wielded against our community and our healthcare.

The ADF wanted it to be true that being trans is just a “phase” and, preposterously, even “a common stage for all cisgender adolescents – a claim that props up the dehumanizing hoax that being transgender is a transmissible social disease:

Substantiate that it is normal during adolescence for children to go through a phase when they identify (to some degree) with the opposite sex. It is inappropriate (and could have psychological, medical, other harms?) to interpret this common stage as gender identity confusion that warrants treating a child as the opposite sex (in language, dress, appearance, etc), and pursuing more drastic measures like hormone therapy and genital change surgery.”

—American College of Pediatricians internal document, “Transgender Research Requests”

The ADF went on to ask ACPeds for a made-to-order argument supporting the desired conclusion that gender-affirming treatment is unhelpful or even harmful to trans people:

“For those who have undergone hormone therapy and genital change surgery, a paper that says they are no happier (and perhaps worse off if the research supports it) even though they took these drastic measures.”

Note that ADF did not ask ACPeds to look for any research supporting the possibility that we are better off with gender-affirming care. Less than four years later, leaders of the American College of Pediatricians provided this legal product to their next customer: the Florida Agency for Health Care Administration.

Because of AHCA’s predetermined conclusion against gender-affirming care, and because of leaders of the American College of Pediatricians and others who served our state agencies a made-to-order right-wing argument in the guise of “professional medical standards”, countless trans adults in Florida are now being forcibly medically detransitioned by the provisions of SB 254.