Thousands of transgender adults are grappling with Florida’s new health landscape after two state medical boards issued new rules for care at the end of June, but some transgender adults and experts feel the new rules potentially do more harm than good.
In May, Gov. Ron DeSantis signed into law Senate Bill 254 which outlaws gender-affirming care for children and restricts how adults receive it. Later in June, the Florida Boards of Medicine and Osteopathic Medicine had a joint meeting to finalize rules surrounding how children and adults previously receiving gender-affirming care could continue to do so under new guidelines.
“It just was really unreasonable," said Lisa Smith, a transgender woman from Orlando.
Smith has been taking estrogen for 23 years but her access to it was cut off after SB 254 prevented nursing practitioners at clinics from prescribing hormone replacement therapy, also know as HRT. Under the new rules, former patients can continue receiving medication but only through a physician and after signing a state-approved informed consent document.
"So really now it's just been finding the right doctor," she said.
However, Smith faces another issue. Actually signing the document.
"It feels invalidating like, we're agreeing that our condition, for lack of a better term, is not valid or based on good evidence. I morally can't agree with that. It feels coerced," she said. "I have to sign this agreement to continue what I've been doing for 23 years. It's like the bully says 'You want this don't you?' And they're gonna mess with you to the point that it's just not even worth it."
In addition to signing the document, Smith, and other transgender adults, will have to consent to a suicidal-risk assessment evaluation every three months, and an evaluation with a psychiatrist or psychologist every two years, on top of the monthly blood work she already had to do before SB 254.
She'll need to do all of that for the duration of her treatment.
"For us treatment is our entire lives. That would involve seeing therapists routinely, forever," she said.
Those who established a prescription with a physician prior to SB 254 can continue to renew their prescriptions for the next six months thanks to an emergency rule established in June.
Smith previously received care from a clinic and can’t get a new prescription without signing the new document. She has one more refill left on her HRT prescription before she would have to seek out a physician. She thinks the prescription will last two months, maybe three if she stretches it out.
Uncertainty of treatment
Even if Smith agrees to proceed with the new rules, she and other transgender people are worried about how another bill could potentially affect them.
The Protections of Medical Conscience law allows a pharmacist to deny a trans person medicine if that pharmacist feels honoring the prescription goes against their ethics, said Jay Wolfson a professor of public health at Stetson University College of Law.
"The 'conscience' law is expressly intended to protect physicians, who do not believe they should perform specific types of clinical services, such as abortion or hormone replacement therapy," he said.
With uncertainty hanging in the air, experts are worried more transgender people, like Smith, may continue to stockpile medication.
"Those medications have a shelf life for a reason," said Syvonne Carter the CEO and President of 26Health — a Central Florida LBGTQ clinic.
Carter is concerned the uncertainty of receiving treatment will cause patients to stockpile and stretch out their reserves, leading to expired medication and unhealthy consequences.
“There may be different things that will grow in that medication like mold and things of that nature. And then medication won't be as effective given that post-expiration time,” Carter said.
Legal confusion
Additionally, Carter is concerned about how quickly laws and state board rules have changed the health landscape creating confusion among patients. She said 26Health is still getting calls every day hoping the clinic offers HRT.
"We have had patients who have debated our interpretation of SB 254," Carter said. "I wouldn’t say I feel that there is a community penetration of understanding the law."
Before SB254, clinics were the largest providers of HRT, but the law has shifted the responsibility solely to physicians, Carter said.
Florida Republican Sen. Clay Yarborough is the sponsor of SB 254. He declined an interview with WMFE but emailed an explanation as to why mid-level healthcare workers, such as nursing practitioners, can no longer offer HRT, explaining that due to the complication of risks associated with the practice, a trained physician is necessary.
"Individuals taking hormone replacements face a substantially increased risk of serious cardiac events, including stroke, heart attack, and pulmonary embolism, according to the American College of Cardiology," Yarborough said in an email to WMFE. "Adults are free to provide voluntary, informed consent and receive prescriptions or procedures, but they should be informed of the nature and risks ahead of time."
Carter is unsure Yarborough's response provides clarity on the decision to remove mid-level healthcare workers as providers of HRT.
“I don't know if there is any evidence-based study that currently stipulates that a nurse practitioner couldn't provide the same mid-level of care or level of care for the community as they have been doing for years in the past,” Carter said.
Transitioning to a new Florida
Alex Sierra feels like being a transgender man in Florida is a lot like being stuck on a railroad track.
"I can't sit and stare at this train all day. But if I don't look at it periodically, I don't know when it's going to hit me," he said.
Alex and his husband Jake, also a transgender man, have a M.D. who reliably provides testosterone, but the added changes in the state have caused both of them mental anguish.
"I feel exhausted and targeted. I haven't slept well in a few months," Jake said. "Sixteen years ago, when I first started, I signed an informed consent when I was 21, and so it just feels like they're trying to make it harder for us to exist."
So much so, the two have spoken about a contingency plan to leave the U.S. if they can no longer receive medication or they feel they're being targeted for violence. For now, they've chosen to stay and help spread useful information for other transgender people, which Alex does via his website UmbrellaGuide.org — a tool for keeping up with transgender health news updates and resources.
More changes to the health landscape could be on the way as efforts to reverse SB 254 are underway. In June, federal judge Robert Hinkle issued an order lifting the ban on such therapies for transgender youth for three families challenging the rules. Hinkle argued that gender identity is real and that denying treatments could lead to significant harm.
The case is set to go to trial on April 15, 2024.
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