FLORIDA HRT CRISIS: S.B. 254, effective May 17, 2023, banned nearly all HRT prescriptions for trans adults — with no end in sight.
It’s been 11 weeks.
August 5, 2023: Update on Boards of Medicine forced consent forms and class action by trans adults against SB 254
The Florida Boards of Medicine and Osteopathy’s Joint Rules/Legislative Committee met on August 3 to consider changes to the emergency rule “informed consent” forms before enacting them as a permanent rule.
Archive video of the meeting: 8/3/23 Florida Boards of Medicine and Osteopathic Medicine Joint Rules/Legislative Committee
- The Joint Administrative Procedures Committee sent a letter to the Boards on July 21 questioning whether they exceeded their statutory authority in requiring trans adults to see a psychologist or psychiatrist before starting HRT and every two years thereafter.
- In response, the Boards indicated that they would ultimately remove the requirement for mental health evaluations.
- However, the Boards decided to postpone finalizing a permanent rule until this October or December.
A recent motion for a preliminary injunction against SB 254’s adult transgender care restrictions, if successful, could eliminate the mandated use of these forms entirely.
Read more from Southern Legal Counsel: Transgender Floridians Seek Emergency Block on Adult Healthcare Restrictions in SB 254
- The third amended complaint in Doe v. Ladapo adds new challenges to section 5 of SB 254, subsections 2 through 5.
- This complaint challenges the ban on nurse practitioners prescribing hormone therapy as part of gender-affirming care, the requirement for physicians to use the Boards’ approved “informed consent” forms, and the requirement for an in-person appointment for initial prescriptions.
- An additional motion seeks to certify all transgender minors and adults in Florida as a class (within one of three classes), and requests classwide injunctive relief. Were this injunction granted, nurse practitioners and physicians, including telehealth providers, would again be able to prescribe HRT for gender-affirming care without being subject to any of the restrictions introduced by SB 254.
What happens now?
- The joint scheduling report of the parties in Doe v. Ladapo sets deadlines of August 7 for Florida to challenge the motion for a preliminary injunction, and August 14 to challenge the motion for a class action certification. The dates for the hearings on these motions have yet to be determined by the court, meaning we do not know when a preliminary injunction might be granted.
- The latest scheduling order (ECF No. 117) sets a date of November 13, 2023 for the trial to begin, and it is estimated to last two days. This is a bench trial, meaning the decision will be made by a judge alone, rather than a jury trial.
- There will be another scheduling conference between the parties on August 10 (ECF No. 119).
We reiterate that this law is creating a continuously unacceptable situation that has jeopardized the health and safety of thousands of trans adults, for no reason whatsoever other than political interference in private medical decisions. Once again, SB 254 must be reversed immediately and the May 16, 2023 status quo must be completely restored.
“This law has got to be completely reversed. The science is on our side.”
—Joey Knoll, CEO and nurse practitioner at SPEKTRUM Health
How you can help trans Floridians
- We ask that you donate to any individual trans person in Florida who needs help, and provide direct assistance with transportation and associated costs.
- SPEKTRUM Health is an NP-led nonprofit clinic providing gender-affirming primary care, serving 2,500 trans people affected by SB 254. Donations to SPEKTRUM Health’s Patient Assistance Fund are allocated directly to patient care, and will help SPEKTRUM continue to provide all other primary care and sexual health services to their trans patients during the legal challenges to SB 254.
- Southern Legal Counsel is a legal nonprofit leading the challenges to SB 254 alongside NCLR, GLAD, and HRC. They won the Dekker v. Weida Medicaid exclusion case for trans Floridians. SLC is funded entirely by grants and donations, and your donation can help trans people continue to fight these unjust laws.
Trans Florida has fought these policies relentlessly every step of the way, because we will never accept the loss of our liberties as equal citizens. After a year of these attacks, we still haven’t gone away. We’re louder than ever. And we’re not going to stop until we take back what’s ours.
—Zinnia Jones, August 5, 2023
Trans care bans were never about “protecting children” — they were about making all trans existence completely impossible.
There are more than one million trans adults in the US.
1 in 14 just lost access to their HRT.
I’m one of them.
Why is everything about SB 254 right now? This is a de facto total adult trans care ban that has been in effect for 11 weeks since it was signed by a far-right governor with presidential ambitions, cutting off tens of thousands of trans adults in Florida from continuing to take their prescribed medications.
- Text of Florida SB 254 enacted as Chapter 2023-90
- “[SB 254] imposes new onerous written consent procedures for gender-affirming care for adults, and requires that all care must be provided by an in-person physician.” (ACLU of Florida)
“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)
Florida SB 254 has crossed the trans community’s red line
“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 are currently almost no reliable routes for trans adults to obtain our prescribed HRT within the state of Florida under most circumstances, as the vast majority of patients receive their prescriptions from nurse practitioners and are now unable to do so. The very few physicians who are experienced in providing this care cannot take on a sudden massive influx of new patients, and these physicians are increasingly reluctant to provide this care at all due to political threats and perceived liability. This is a red line for all of us:
- The trans community’s continued and uninterrupted access to our established, medically necessary prescriptions is not negotiable.
- It is not acceptable for Florida’s trans adults to have our human rights violated by being forced to discontinue an ongoing medical treatment for even one single day. There is no tolerable amount of time for this ban to remain in place.
- No individual provision of SB 254 can remain in effect to any degree. No component of these baseless and unprecedented restrictions is acceptable now or at any point – the effects of SB 254 must be mitigated totally.
The state of Florida has crossed this red line for 11 weeks at the time of this writing.
The only acceptable answer is the restoration of the May 16, 2023 status quo, and the resumption of uninterrupted prescriptions of HRT to adults under the previous community standards of care, via their existing providers. Under no circumstances will this change, and under no circumstances can this basic expectation be lowered to any degree.
Accepting the impact of forced medical detransition on our bodies is not an option, as this is known to cause real physical and mental harm to us.
“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)
Leaving the state is also not a realistic or scalable option: Florida has the second-largest adult trans population in the country after California. 94,900-100,000 adult trans people are affected by this ban according to figures provided by the Williams Institute (Herman et al., June 2022) and SPEKTRUM Health gender clinics in central Florida.
The state of Florida cannot be allowed to make 100,000 people into internal refugees of the United States. That will never be an acceptable answer. This is our home.
100,000 people cannot be relocated out of Florida
“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
94,900-100,000 adults cannot leave on short notice from our families and from the entire lives we’ve built as community members living peacefully in Florida until May 17, 2023. Bans on gender-affirming care for adults have a devastating impact on the trans community, far beyond any attack on trans healthcare seen to date. An estimated 16,200 trans youth in Florida are affected by the ban on gender-affirming care, and so are six times more trans adults.
In one day, Florida opened the single largest front in a nationwide fight.
15 states, including Florida, currently ban gender-affirming treatment for trans youth* – affecting an estimated 47,800 youth nationally (Movement Advancement Project, May 28, 2023; Herman et al., June 2022). Texas is soon expected to enact a trans youth care ban as well, which will raise the number of affected youth to 77,600.
This unprecedented wave of legislation targeting trans youth care built the foundation for what happened next: 94,900-100,000 more trans people instantly lost access to their medically necessary gender-affirming care. Now, one state, in one day, can act to harm vastly more trans people than ever before.
One day changed everything: Trans adults in Florida are being cut off from their existing prescriptions and forced to find other providers
The impact of SB 254 on all HRT prescriptions was immediate, highly disruptive, and comprehensive in its interference: After two weeks of this law being in effect, it became clear from reports in the community that almost no trans adults in Florida were able to receive refills or renewals of even their existing prescriptions from many providers.
How did SB 254 cause this unprecedented degree and scope of mass medical harm and human rights violations? At Gender Analysis, we have made continuous efforts to gather information from providers, patients, and other stakeholders since SB 254 took effect, and our assessment of the law’s impact incorporates the best evidence available to us at this time.
The ruinous impact of SB 254 on trans adults and our providers:
Florida Senate Bill 254, signed into law by Governor Ron DeSantis with immediate effect on May 17, 2023, has left almost all providers of HRT for trans adults – most of whom are nurse practitioners (NPs) – with no clear route for their established patients to continue accessing refills and renewals of their stable HRT prescriptions.
- Trans adults who have been taking their prescribed HRT under the care of their provider for months or decades are now almost entirely unable to continue accessing their prescriptions.
- This is a worst-case scenario for trans people of every age in Florida: forced medical detransition. That worst-case scenario has been a fact for 11 weeks.
An estimated 80% of trans adults in Florida are prescribed HRT from an NP. Prescribers other than MDs and DOs are uniquely prohibited by SB 254 from prescribing gender-affirming hormone therapy to adults, and cannot write new prescriptions or renewals of existing prescriptions.
- No such prohibitions on NPs prescribing HRT have ever been in effect in Florida or other states to date, and there is no basis for this arbitrary and disruptive new restriction. Nurse practitioners are practitioners and can prescribe medications in all 50 states in the same manner as physicians.
- In every other state, and in Florida before May 2023, NPs can and do provide HRT assessment, prescriptions, and monitoring according to the same established community standards as MDs and DOs.
- Physicians prescribing HRT are in the minority of HRT-providing practitioners in Florida, and they will not be able to serve the vast majority of trans adults who are now capriciously forced to find a new provider.
Even MDs and DOs who previously provided HRT have now widely elected not to offer new HRT prescriptions or prescription renewals.
- 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 about multiple mutually exclusive procedures, and a recent challenge to SB 254 in Doe v. Ladapo argues that these forms are not adequate to obtain valid consent.
Trans adults in Florida also 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 will impose new burdens on countless trans adults, such as lost wages from taking time off work, and the time and expense of driving most of a day or taking a flight out of state to receive one prescription.
All of these burdens will leave most of us unable to access this care or continue receiving our treatment at all, and these barriers were never imposed on any of us before May 17, 2023.
The existence of trans people is an innate feature of any human community: no jurisdiction can be allowed to become a ‘trans-free zone’.
As with cis people, trans people will always come into existence in any region, meaning that not one trans person can be abandoned to these brutal and torturous policies anywhere. We must fight this and we need you to fight alongside us until this emergency is resolved.
If this is allowed to happen to a hundred thousand trans adults in Florida, it is that much easier to allow this to happen to another hundred thousand of us: other states will realize this is an option on the table now, and you could be the next one to be forcibly medically detransitioned along with everyone else around you.
The entire country is softened up and ready to entertain that conversation now.
SB 254 has put everything at stake for everyone. You are in the sights of their Overton window as of May 17. There has never been a mass all-ages forced detransition on this scale – until now. Now it is a precedent and a model.
In 11 years of medically transitioning in Florida since the age of 23, I have never seen us face a crisis of this existential scale. Because this was dismissed as unthinkable, almost nobody thought about it – but everyone who told us that this would never happen to us was wrong. Are you being told right now that this will never happen to you? I cannot truthfully represent such a promise or guarantee to you. Neither can anyone else.
This is a new and uniquely dangerous event in history and it is a singular point where I wish to emphasize as strongly as possible, drawing on any goodwill and trust you have ever had in me personally as Zinnia Jones or in the work of Gender Analysis: We need to stop this here. We need to stop it now — or we will lose everything. This is an emergency! We are calling for help!
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 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 (WIRED.com, Doctors Behind Mifepristone Ban Called ‘Christians’ a Top Threat)
ACPeds leaders, committee members, and affiliates – including Quentin Van Meter, Andre Van Mol, Paul Hruz, 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” (October 5-6, 2018)
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”, thousands of trans adults in Florida are now being forcibly medically detransitioned by the provisions of SB 254.
What can we do for trans Floridians today?
Trans people are here in Florida for the long term: a mass exodus of 100,000 people and their families is not on the table, and we refuse to allow Florida to make us refugees within our own country. We know what’s needed in Florida to sustain a permanent transgender community through this crisis and beyond.
Support SPEKTRUM Health:
Those wishing to materially help trans people and our providers in Florida, as directly and immediately as possible, should donate to individual trans Floridians in need of help, and to our local gender clinics and nurse practitioners who are facing an unprecedented attack on their practices. Tens of thousands of trans people in Florida will continue to need routine healthcare such as:
- Gender-affirming primary care
- Counseling, psychotherapy, psychiatric care and other mental health services
- Assessment of gender concerns and referral letters for starting gender-affirming treatment
- Blood tests for routine monitoring when starting or resuming gender-affirming hormone therapy
We currently recommend donating to SPEKTRUM Health Orlando and Melbourne, as this is the only fund we have been able to verify as allocating all donations directly to clinic operations and care for trans patients within Florida.
Support Southern Legal Counsel:
We also recommend donating to Southern Legal Counsel, a Florida non-profit leading the legal challenges against AHCA’s Medicaid exclusion, the Boards’ trans youth care bans, and SB 254. Challenges to SB 254’s adult care restrictions have also been included in this ongoing litigation — Southern Legal Counsel is already fighting to stop this law. SLC is funded entirely by donations and grants.
We will continue listing additional funds as we assess their use and distribution of donations to the Florida trans community, our providers, and ongoing litigation by our local nonprofits. Gender Analysis is here in Orlando and ready to fight for the trans people of Florida. We’re not going anywhere.
* This includes: Florida (16,200 trans youth affected), Georgia (8,500), Idaho (1,000), Indiana (4,100), Iowa (2,100), Kentucky (2,000), Mississippi (2,400), Missouri (2,900), Montana (500), Nebraska (1,200), North Dakota (500), South Dakota (500), Tennessee (3,100), Utah (2,100), and West Virginia (700), totaling 47,800 trans youth affected by current bans (Herman et al., June 2022).
Note: Trans youth care bans in Alabama and Arkansas have been stayed pending appeal. Oklahoma’s trans youth care ban is subject to a binding non-enforcement agreement as of May 18, 2023 (Movement Advancement Project, May 28, 2023).