Between Oath and Legislation: Navigating Bioethical Dilemmas in Gender-Affirming Care amidst Anti-Transgender Legislation

Background and purpose: In an era marked by an alarming increase in anti-transgender legislation across the United States, the provision of gender-affirming care to transgender and gender-diverse (TGD) adolescents stands at a critical juncture. This study investigates the profound bioethical dilemmas faced by Adolescent Gender-Affirming Providers (AGAPs), who are caught between the ethical imperatives of their profession and the restrictive mandates of emerging legislation. By focusing on principles of autonomy, justice, beneficence, and non-maleficence, our research sheds light on the anticipatory anxiety, moral distress, and broader "chilling effects" these laws impose on healthcare providers and their capacity to offer care. This study carried two distinct aims. Our first aim was to understand the ethical impacts of anti-transgender legislation on AGAPs. Our second aim was to understand AGAPs’ perspective on bioethical dilemmas arising from anti-transgender legislation.

Methods: Between March and July 2022, in-depth interviews were conducted with 32 AGAPs working in states with active or proposed bans on gender-affirming medical care for adolescents. Participants were selected through professional listservs and snowball sampling, ensuring a diverse representation across the South and Midwest regions. Our analytical framework employed thematic analysis, leveraging both inductive and deductive coding strategies, using MAXQDA Plus software. Special attention was given to ethical considerations, with robust measures for participant anonymity and data security. The research team, comprised of individuals with diverse gender identities, including queer and trans perspectives, ensured a nuanced interpretation of the data. The study was deemed exempt from review by the IRB and participants provided informed consent, with measures taken to ensure anonymity and confidentiality.

Findings: Half (n=16) of the sample practiced as a Physician (MD/DO), 19% (n=6) were Clinical Psychologists, 16% (n=5) were Counselors or Therapists, 6% (n=2) were Nurse Practitioners, and one interviewee was a Chaplain. The central theme from our analysis unveiled the deep ethical quandaries AGAPs navigate in the face of anti-transgender legislation; they stand at the intersection of their commitment to “do no harm” and the legal risks associated with offering necessary care. Participants articulated experiences of stress, professional risk, and ethical conflict, which, in turn, affect their ability to deliver comprehensive and compassionate care to TGD adolescents.

Conclusions and implications: The findings illuminate the critical bioethical challenges faced by AGAPs, exacerbated by anti-transgender legislation. The restrictive legal landscape not only undermines the autonomy of TGD youth and their right to access care but also places healthcare providers in ethically untenable positions, destabilizing the core principles of medical ethics. Our findings highlight the need for reevaluating legislative approaches to gender-affirming care, advocating for policies that align with the core bioethical principles of healthcare practice. As these legislative landscapes continue to evolve, it is imperative that discussions and policies consider the significant ethical implications for both healthcare providers and the TGD individuals they serve.