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Southern Hospitality Isn’t Conditional: Stop Anti-Trans Legislation

Anti-trans legislation is sweeping across America, specifically heating up in the Southeast. Bills like H4776 and laws like “The Vulnerable Child Compassion and Protection Act” recently passed in Alabama negatively impact the health of transgender kids and further put them at risk for negative mental health outcomes.

Thomas Agostini

Fellow, Medical University of South Carolina, 2022

I’ve always been enchanted with the idea of Southern Hospitality. As southerners, we anchor our identities in universal kindness towards our neighbors and complete strangers. The philosophy stands to treat everyone with unrelenting warmth and affection, but this principle continues to dwindle and exclude transgender kids.

I remember being in our pediatric gender clinic one day during my second year of medical school. Not once did the physician forget to tell her trans and nonbinary patients, “I’m so proud of you. Even though it shouldn’t be, coming out is tough and you’re so brave for doing so.” I cannot tell you how many children and loved ones I saw tear up that day after she would say that. As we stepped out of the room, the physician pulled me aside and said, “You never know what these kids have been through. That might be the first time anyone told them that they were proud of them.”

Most patients were being seen for the first time, bringing family members who may or may not have been supportive to speak to the endocrinologists about potential options, but there was one returning patient that sticks out in my mind. This patient had been on hormones for over a year and had the biggest smile on their face when we walked in. The first thing I noticed when I walked in the room was that the parent accompanying the teen was entirely decked out in Pride gear. It warmed my heart to see such a supportive parent who publicly showed support for her trans kid. As we were talking, recent changes in legislation came up. There was a bill looming in South Carolina legislation that would criminalize gender affirming hormone therapy and puberty blockers to trans and nonbinary youth. The family couldn’t help but ask what would happen if this were signed into law – they had to drive for hours to come see this doctor as she’s one of only two Pediatric Endocrinologists in the entire state of South Carolina that provide gender affirming hormone therapy. The barriers faced by families seeking willing providers were already excessive, and outright banning it in the state would only make matters worse. The doctor’s response, however, will stay with me forever. She looked them in the eyes and said, “I’m not going anywhere.”

Alabama recently passed a law that criminalizes providing puberty blocking agents and gender affirming hormone therapy by up to 10 years in prison [1]. Healthcare providers could spend up to 10 years in prison simply for providing the standard of care to their transgender and nonbinary patients. These medical therapies have such strong data in improving mental health outcomes that all major medical organizations have guidelines to support their use for trans kids who would like to delay puberty or begin hormone therapy. Recently the AAFP, AAP, AMA, AAMC, APA, the Endocrine Society, and many other major medical organizations filed an amicus brief in support of trans youth for this case [2]. The physicians behind this brief go into excruciating detail about the robust literature and data to support these interventions for trans and nonbinary children who may benefit. Fortunately, this law was blocked by a federal judge and did not go into effect.

Gender affirming therapies have been linked to better mental health outcomes and decreased suicidal ideation. Access to gender affirming during early adolescence was associated with a decreased risk of suicidal ideation by 60% in early adolescence, 50% in late adolescence, and 20% in adulthood [3]. Trans and nonbinary kids who wanted and received puberty blockers were 70% less likely to endorse suicidal ideation compared to their peers who did not receive blockers, adjusting for demographics and family support [4]. Preventing trans kids from accessing this care does nothing but perpetuate stigma and place children in harm’s way.

South Carolina is en route to join ranks with Alabama, passing SC H4776. This bill, falsely labeled the “Medical Ethics and Diversity Act,” authorizes healthcare providers to discriminate and refuse services on religious or unspecified personal grounds [5]. By doing so, H4776 will allow providers to deny services to patients like gender-affirming care, family planning options, treatment and prevention of HIV or other STIs, and many more services for LGBTQ+ individuals. In a state that refuses to expand Medicaid, enough gatekeeping exists around medical services. This bill, if signed into law by Governor McMaster, will only further exclude trans and nonbinary people from receiving care that could potentially be life-saving.

Over a year ago, legislators in Arkansas passed a law overriding the Governor’s veto of banning gender affirming care for kids [6]. Thankfully, the law was blocked by a Federal Court before it could go into effect. Just because it was overruled, however, does not mean it didn’t have rippling impacts. The Fenway Institute eloquently highlights how anti-trans legislation has been linked to negative mental health outcomes for gender diverse individuals [7,9]. The exposure to negative depictions of transgender people in the media, including the media coverage of anti-transgender legislation, is associated with clinical symptoms of depression, anxiety, and PTSD [9]. Even if these bills fail or get blocked by the federal courts, like the Alabama law, the berating dialogue dehumanizing trans and nonbinary individuals will continue to have deleterious impacts on their mental health.

The recent uproar of anti-trans legislation sends a clear message to gender diverse youth that legislators don’t care about them. This is why I believe as medical providers we must stand up to advocate for our patients, and to show our support for them and the services they’re entitled to. As a medical student, I have seen the impact these bills have had on the mental health of transgender kids. Trans youth are already more at risk for depression, anxiety, and dying by suicide compared to their cisgender peers, and anti-trans legislation only makes matters worse. Research through the Trevor Project suggests LGBTQ youth who report having at least one accepting adult were 40% less likely to report a suicide attempt [8]. This includes family members, friends, and healthcare workers.

As current and future providers, we can show our patients how much we care about them outside of clinic by organizing protests, contacting state officials, and publicly challenging the misinformation being spread about the LGBTQ+ community. As anti-trans legislation has been introduced here in my home state, trans and nonbinary individuals have rallied around the state house, advocating for their rights. Residents, attendings, and healthcare students have joined them by testifying in front of state officials. Medical professionals debunking the myths presented only helps arm legislators with data-driven recommendations to protect trans kids and their providers.

Just as the Pediatric Endocrinologist told her patient, “I’m not going anywhere,” we as a medical community need to outwardly advocate for our trans and nonbinary patients. By showing this support, we will hopefully show them that their doctors, nurses, and clinical staff are here to make sure they get the services and humane treatment they deserve. This is not to say we should speak for them, but rather we should use our societal privilege to amplify the voices of our patients who are most impacted by the misinformation presented to legislators. I urge everyone to seriously consider why it is they think that bills like H4776 are necessary. At the end of the day, legislation like this only places LGTBQ+ youth in harm’s way.


1. Chandler K. Transgender treatment, doctors threatened by new Alabama Law. AP NEWS. Published May 9, 2022. Accessed May 12, 2022.

2. Rev. Paul A. Eknes-Tucker Et Al., Plaintiffs, V. Kay Ivey, Et Al. Defendants.(Middle District Of Alabama Northern Division 2022).

3. Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLOS ONE, 17(1).

4. 9. Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics. 2020 Feb;145(2):e20191725. doi: 10.1542/peds.2019-1725. Erratum in: Pediatrics. 2021Apr;147(4): PMID: 31974216; PMCID: PMC7073269.

5. Polaski A. South Carolina Senate passes "license to discriminate" in Healthcare bill. South Carolina United for Justice & Equality. /updates/south-carolina-senate-passes-license-to-discriminate-in-healthcare-bill. Published May 11, 2022. Accessed May 12, 2022.

6. Cole D. Arkansas becomes first state to outlaw gender-affirming treatment for Trans youth | CNN politics. CNN. Published April 6, 2021. Accessed May 12, 2022.

7. Richgels, C., Cahill, S., Thompson, J., & Dunn, M. (2021). State bills restricting access of transgender youth to health care, school facilities, and school athletics threaten health and well-being. Fenway Institute, 10–12.

8. Accepting adults reduce suicide attempts among LGBTQ youth. The Trevor Project. Published October 5, 2021. Accessed May 12, 2022.

9. Hughto JMW, Pletta D, Gordon L, Cahill S, Mimiaga MJ, Reisner SL. Negative transgender-related media messages are associated with adverse mental health outcomes in a Multistate Study of Transgender Adults. LGBT Health. 2021;8(1):32-41. doi:10.1089/lgbt.2020.0279

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