The Impact of Legislative Restrictions and Provider Identity on Gender-Affirming Care Clinicians’ Well-Being

Background and Purpose:
Clinicians providing gender-affirming (GA) care are increasingly exposed to hostile policy environments that may elevate burnout and psychological distress. These challenges are particularly acute for trans and gender-expansive (TGE) providers, who experience compounding personal and professional stressors. We addressed two research questions: (1) Are state-level legislative restrictions associated with differences in burnout, secondary traumatic stress (STS), compassion satisfaction, coping, or psychological distress? (2) Do outcomes differ between TGE and cisgender providers?

Methods:
A cross-sectional survey was administered between April and August 2024 to a purposive sample of GA care providers recruited via professional networks (e.g., WPATH, PACT, LGBTQ+ Healthcare Directory). Eligible participants included medical, mental health, and social service professionals currently providing GA care in the United States. IRB approval was obtained. We used a cross-sectional survey design to assess real-time differences in provider outcomes by policy environment and identity-based stressors during a period of legislative change.

A total of 142 participants completed a 92-item online survey including the Professional Quality of Life Scale (ProQOL), Kessler Psychological Distress Scale (K6), and Brief Resilient Coping Scale (BRCS), alongside demographic and practice information. State-level policy environment (restrictive vs. non-restrictive) was classified based on enacted legislative restrictions on GA care. MANCOVA tested differences in provider outcomes by policy environment, controlling for gender identity, years of experience, and patient population (pediatrics vs. adults). A separate MANOVA tested differences between TGE and cisgender providers. Less than 5% of data were missing and handled via listwise deletion.

Results:
Respondents (N = 142) represented diverse genders and licensures, with 41.5% practicing in states with legislative restrictions on gender-affirming care. Overall, providers reported moderate psychological distress (M = 13.83, SD = 5.13), moderate to high compassion satisfaction (M = 38.18, SD = 6.55), low to moderate burnout (M = 23.75, SD = 6.26), and predominantly low secondary traumatic stress (M = 19.73, SD = 5.55).

A MANCOVA revealed no significant overall differences between providers in restrictive vs. non-restrictive states; however, univariate results showed higher compassion satisfaction among providers in restrictive states (p = .013). No significant group differences were found for burnout, coping, STS, or distress. A second MANOVA revealed significant multivariate effects of gender identity on the full model (p < .001). TGE providers reported significantly higher secondary traumatic stress (p = .014) and psychological distress (p < .001) than cisgender peers. Differences in coping approached significance (p = .051), with no differences in burnout or compassion satisfaction.

Conclusions and Implications:
While legislative context did not universally worsen burnout or distress, it was associated with increased compassion satisfaction. In contrast, gender identity emerged as a critical factor in provider well-being, underscoring the vulnerability of TGE clinicians. These findings emphasize the need for targeted interventions to support clinician resilience. This study highlights the importance of research-informed organizational strategies to prevent resource depletion and promote equitable, affirming care and sustain the behavioral health workforce, particularly in politically charged contexts.