Legislative Restrictions on Gender-Affirming Medical Care: Ethical Challenges for Mental Health Professionals

Archives > Volume 22 (2025) > Issue 2 > Item 05

DOI: 10.55521/10-022-205

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Allan Edward Barsky, PhD, MSW, JD
abarsky@fau.edu
Professor, Florida Atlantic University
https://orcid.org/0000-0003-4768-0712

David Simpson, PhD, MSSA, LCSW (IL)
simpsond@fau.edu
Assistant Professor, Florida Atlantic University
https://orcid.org/0000-0002-0286-7703

Abstract

In 2023, the state of Florida enacted legislation that imposed significant restrictions on access to gender-affirming medical care for transgender and gender-diverse individuals. These restrictions included a comprehensive ban on gender-affirming medical care for minors and bans on using state funds to provide gender-affirming medical care for adults (i.e., Medicaid). This study explored the ethical issues encountered by mental health professionals in light of the legislative restrictions on access to gender-affirming medical care. MHPs reported substantial ethical challenges related to: (1) beneficence and nonmaleficence; (2) autonomy, self-determination, and informed consent; (3) commitment to responsible practice; (4) ethical-legal conflicts; (5) honesty and transparency; (6) privacy and confidentiality; and (7) respecting the dignity and worth of the person.

Key words:
gender-affirming medical care, transgender, mental health practice, ethics, law

Introduction

Gender-affirming medical care (GAMC) refers to the use of puberty blockers, hormone treatments, and surgeries to help transgender and gender-diverse (TGD) individuals affirm their gender identities. These interventions help TGD individuals align their physical body with their gender identity, often improving their psychological wellbeing and reducing gender dysphoria (Coleman et al., 2022). Before TGD individuals make use of GAMC, they often engage in social and behavioral transitions, including changes in names, pronouns, clothing, hairstyle, manner of presentation, social activities, use of gendered spaces (such as bathrooms), and legal documentation (Reynolds & Goldstein, 2014). Accessing gender-affirming care to support medical and social transitions can reduce the risks of depression, anxiety, substance abuse, and suicide, and promote positive psychosocial wellbeing (Abreu et al., 2022; Coleman et al., 2022).

Since 2021, several states have passed laws restricting GAMC for minors, adults, or both. This article explores the impact of a law, Florida Senate Bill 254 (SB-254), which bans access to GAMC for minors and restricts access for adults. In particular, this article presents the findings of a qualitative study that invited licensed mental health professionals (MHPs) to describe ethical challenges they have encountered following the restrictions placed on GAMC by SB-254.

The first part of this article provides a literature review describing SB-254’s impact and exploring the research on GAMC’s effectiveness. The methods section describes the qualitative methods used to gather information from MHPs to learn about how their practice with TGD individuals was affected in the first year after SB-254’s passage. The findings section presents the primary themes derived from interviews, with examples of the ethical issues that MHPs encountered following the passage of SB-254. The limitations section outlines factors to be considered when interpreting the findings and considering the extent to which they are transferable to other jurisdictions with similar laws. The final section explores the implications of this study for future policy, mental health practice, and research.

Literature Review

Gender variance has been recognized by health professionals for centuries, dating back to at least 400 BCE as documented in Hippocrates’ On Airs, Waters, and Places (Oles et al., 2025). Records of gender-affirming surgery for intersex individuals date to the second century BCE. In modern medicine, GAMC for TGD individuals has a history spanning over 100 years, with the first documented hormone treatments and surgeries occurring 1920s Europe (Mumford, 2023; Oles et al., 2025). Since the 1970s, GAMC has gained increasing research support and acceptance (Lothstein, 1982). Currently, the National Association of Social Workers (NASW), American Psychological Association (APA), American Medical Association (AMA), American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and most other major American health and mental health associations support its use as an evidence-based intervention for TGD minors and adults (APA, 2024; Doe v. Ladapo, 2024; GLAAD, 2024). Internationally, GAMC’s value has been recognized by the World Professional Association for Transgender Health (WPATH), which provides research-based standards of care for GAMC treatments such as puberty blockers, hormone treatments, and gender-affirming surgeries (Coleman et al., 2022). Other countries with GAMC practice standards include Denmark, Norway, Sweden, Australia, United Kingdom, and Netherlands (Taylor et al., 2025). These guidelines emphasize individualized assessments to ensure each patient receives the most appropriate care.

GAMC and the Law

Despite the broad acceptance of GAMC within health and mental health professions, various state and national governments have enacted laws restricting its use or denying recognition of the existence of people with TGD identities. In 2025, President Donald Trump signed an executive order asserting that only two gender identities exist—male and female (White House, 2025a). He signed a second order prohibiting GAMC for minors (White House, 2025b). As of February 2025, 26 states have passed laws restricting access to GAMC (Human Rights Campaign, 2024). These restrictions vary by state, with some focusing on restrictions for minors and others extending restrictions to adults. Florida was among the first states to pass such legislation. In 2023, the Florida Senate passed Bill 254 (SB-254), titled “Treatments for Sex Reassignment,”¹ which imposed several restrictions on GAMC, including:

• prohibiting “sex reassignment prescriptions or procedures” (puberty blockers, hormone therapies, and surgeries) for individuals under 18, with limited exceptions for minors already receiving treatment;
• requiring that “sex reassignment” prescriptions and procedures for adults be prescribed only by licensed medical, allopathic, or osteopathic physicians;²
• mandating that consent for sex-reassignment treatments for adults be voluntary, informed, and written, and provided in the physical presence of the treating physician; and
• prohibiting Medicaid funding for GAMC.

SB-254’s proponents argue that GAMC is inappropriate for minors citing concerns about potential harm, fertility implications, and the possibility of regret should a minor’s gender identity change over time. Some proponents assert that gender is binary and immutable. Some proponents claim that physicians do not take sufficient time to conduct appropriate assessments to ensure that GAMC is medically necessary, while others question the validity of studies supporting GAMC’s efficacy (Cass et al., 2024; Doe v. Ladapo, 2024; Levine & Abbruzzese, 2023). Other proponents have suggested that transgender identities are not “real” and that people are claiming this identity due to social influence, deception, or psychological distress (Dekker v. Weida, 2024; White House, 2025a).

Some opponents of GAMC cite religious beliefs as the basis of their objections. From a Christian perspective, Genesis 1:31 states that people are created in God’s image and “God’s design for his creation is very good” (Genesis, 1:31). Additionally, Matthew 18:6 underscores the responsibility to protect children from harm. Evangelical Christian scholar Hough (2024) argues that when children experience gender dysphoria, “We must be patient, listen to them, pray for them, teach them, and, when necessary, connect them with a professional Christian counselor” (n.p.). He contends that social or medical transitions are inappropriate.

Supporters of GAMC restrictions for adults often raise concerns about its effectiveness and risks. While state and federal laws generally grant adults the right to make their own medical care decisions, restrictions on the use of Medicaid to fund GAMC are based on the belief that public funds should not be allocated to support GAMC. In Dekker v. Weida (2024), a Florida court issued an injunction against this provision, ruling that GAMC constitutes evidence-based medical care. The court found no legitimate state interest for prohibiting GAMC, and determined that passage of SB-254 was influenced by bias and anti-transgender sentiment rather than medical or scientific justification.

SB-254’s requirement that consent to GAMC be informed and in writing has not been challenged in court; informed written consent is standard practice for various medical procedures (AMA, 2016). Requiring in-person consent to hormone treatments is dubious because various telehealth services are offered without concern about whether consent is provided in-person (Agency for Healthcare Research and Quality, 2020). Similarly, the requirement that prescriptions be provided by physicians—and not nurse practitioners—does not have a persuasive legal justification. Nurse practitioners have broad authority to prescribe controlled substances in all 50 states (AMA, 2017).

Research on the impact of specific legislative restrictions on GAMC remains limited. However, a survey of 134 parents of TGD individuals across multiple states found that laws banning GAMC for minors were associated with increased rates of anxiety, depression, and suicidal ideation, and more severe gender dysphoria states (Abreu et al., 2022). These laws contributed to feelings of decreased safety, heightened anti-transgender stigma, and increased barriers to necessary health care. Participants urged legislators to avoid politicizing healthcare for the TGD community and advocated for legalizing GAMC for minors. They emphasized allowing minors and their families to make healthcare decisions in consultation with healthcare professionals rather than having those decisions dictated by lawmakers. Participants suggested that lifting GAMC bans could reduce societal stigma against the transgender community.

Kidd et al. (2021) surveyed 273 caretakers of TGD minors across several states to share their perspectives on proposed legislation banning GAMC for minors. The caretakers’ primary concerns included reduced access to essential medical care, undermining their children’s autonomy in making healthcare decisions, and increasing mental health conditions such as anxiety, depression, and suicidal ideation. They advocated for policies allowing TGD minors and families, in consultation with their medical professionals, to make these critical healthcare decisions without government interference.

The Human Rights Campaign (2023) conducted a nationwide survey of 14,000 LGBTQ+ adults to assess the impact of GAMC bans. In Florida, nearly 80% of TGD adults reported that these bans negatively affected their physical and/or mental health or that of their loved ones. Over 93% said these bans made them feel less safe. More than 80% expressed a desire to leave Florida or had already taken steps to relocate due to these bans (Human Rights Campaign, 2023). 

Multiple lower courts have issued injunctions against GAMC bans, ruling that they violate the due process and equal protection clauses of the Fourteenth Amendment (Doe v. Ladapo, 2024; Poe v. Labrador, 2023). These rulings have found that GAMC bans unjustly target TGD minors by criminalizing medical treatment for them, while allowing other minors and their parents to make healthcare decisions without similar restrictions (Howe, 2024). In essence, the bans discriminate based on sex and transgender status. In a 6-3 decision, however, the United States Supreme Court upheld Tennessee’s legislative ban on GAMC for minors (United States v. Skrmetti, 2025). This precedent suggests that similar bans in other states are constitutionally valid. The majority in Skrmetti held that states have a right to regulate medical procedures, including bans on procedures that they believe are harmful or risky. The Supreme Court rejected arguments that such bans violate TGD youths’ constitutional right to equal protection. The plaintiffs had argued that GAMC bans discriminated against them on the basis of sex or gender. In her dissenting opinion, Justice Sonja Sotomayor wrote, “If left untreated, gender dysphoria can lead to severe anxiety, depression, eating disorders, substance abuse, self-harm, and suicidality.” She suggested that the majority decision would cause serious harm to transgender children and their families.

Hollinsaid et al. (2022) conducted a study comparing the availability of mental health services for TGD adolescents in the U.S., comparing services in states with laws that have varying degrees of restrictiveness in relation to TGD individuals. They found that states with more restrictive laws have substantially fewer transgender-specific adolescent mental health providers per capita. This research supports the contention that discriminatory laws and policies negatively affect the availability of mental health providers for the TGD community, and not just the availability of medical treatments.

Ethical Obligations

Social workers and other mental health professionals have ethical duties to respect the dignity and worth of all people, promote the wellbeing of their clients, and ensure access to needed services. These duties are guided by principles of client self-determination and informed consent (American Counseling Association [ACA], 2022; APA, 2016, 2017; NASW, 2021). These principles align with those of medical professionals, including the biomedical ethics principles of beneficence (promoting wellbeing), nonmaleficence (avoiding harm), autonomy (respecting individual choice), and justice (ensuring fair distribution to resources) (Beauchamp & Childress, 2019). In the context of GAMC, these principles suggest that MHPs should respect the choices of their clients, provided that their decisions are based on informed consent. For minors, this process should also involve parental or guardian consent (Barsky, 2023 & 2024). When clients seek support for GAMC, MHPs can play pivotal roles in conducting comprehensive assessments and facilitating informed decision-making. They draw on current research and evidence-based practice standards, and, where appropriate, collaborate with medical professionals and family members (Coleman et al., 2022). The informed consent process should include discussion of all service options, along with the potential benefits and risks of each (Barsky, in press). Notably, many TGD individuals do not pursue GAMC. Some may experience no gender dysphoria, some may opt for social transitions without medical intervention, some may want to wait for GAMC until they are adults, and others may decide that GAMC is not in their best interests.

Given the statutory restrictions on GAMC, MHPs may encounter ethical-legal conflicts when clients seek help accessing care. While MHPs have an ethical obligation to help clients access services that can assist with their mental health and social wellbeing, laws restricting GAMC can hinder or prevent them from fulfilling this duty. There have been few studies that have explored the ethical challenges faced by health and mental health care professionals when helping clients make decisions about GAMC (Gerritse et al., 2022). These ethical issues can be even more challenging in jurisdictions with legal restrictions on access to GAMC. The present study explored MHPs’ experiences and perspectives on navigating legal-ethical dilemmas that have arisen since passage of SB-254.

Methods

This research employed a qualitative, phenomenological approach (Denzin & Lincoln, 2017) to study ethical challenges encountered by MHPs after SB-254’s enactment. Prior to contacting research participants, the researchers obtained IRB approval for these research methods from Florida Atlantic University. Using convenience sampling, 17 licensed mental health professionals who served TGD clients in Florida were recruited. Recruitment involved emailing invitations to MHPs whose websites indicated experience working with TGD clients or who were members of professional organizations specializing in this population. After obtaining informed consent, the first author conducted an in-depth semi-structured interview via videoconferencing. Open-ended questions were used to explore ethical issues encountered by MHPs following SB-254’s enactment. Follow-up prompts were used to encourage MHPs to share detailed narratives and examples of ethical challenges. Each interview was videorecorded and transcribed.

To safeguard confidentiality, the first author removed all identifying information during transcription and deleted the video recordings upon completion. Thematic qualitative analysis was conducted using an inductive, semantic approach (Iphofen & Tolichm, 2018). The first author systematically reviewed each transcript, employing word coding techniques to identify patterns of words, phrases, and underlying meanings. Common themes were then identified across transcripts (Denzin & Lincoln, 2017). To enhance the accuracy and dependability of the analysis, the second author independently audited the transcripts, codes, notes, and themes (Carcary, 2020). Discrepancy between their respective codes and themes were discussed until consensus was reached, ensuring that the findings accurately reflected the participants’ experiences and perspectives.

Findings

The study sample comprised 17 licensed MHPs, including 10 licensed clinical social workers, 5 licensed mental health professionals, 1 licensed psychologist, and 1 licensed family and marriage therapist, all of whom served TGD clients. Participants had various levels of post-licensure practice experience: 3 had between 1 and 5 years, 8 had 6 to 10 years, 2 had 11 to 15 years, 2 had 21 to 25 years, and 2 had 25 to 30 years. Geographically, 14 participants were based in South Florida, 3 in Central Florida, and 1 in North Florida, with one maintaining offices in multiple regions. Ten participants also provided services statewide via videoconferencing.

The vast majority of MHPs (15 of 17) reported that SB-254 introduced significant ethical issues in their work with TGD clients. MHPs noted that SB-254 made their practice with TGD clients “more complicated,” often resulting in anguish or moral distress as they navigated how to uphold professional standards and “best practices” given the restrictions that SB-254 placed on access to GAMC. Only two MHPs suggested that SB-254 did not pose significant ethical concerns in their practice. Analysis of the ethical concerns identified by MHP revealed seven primary themes: beneficence and nonmaleficence; autonomy, self-determination, and informed consent; commitment to responsible practice; ethical-legal conflicts; honesty and transparency; privacy and confidentiality; and respect for the dignity and worth of the person. The following sections provide in-depth exploration of each theme.

Beneficence and Nonmaleficence

The principles of beneficence and nonmaleficence guide MHPs to promote good and avoid causing harm. Many MHPs suggested that SB-254 not only obstructs their ability to do good for clients, but also causes direct harm to TGD clients in need of GAMC. Some MHPs believed that SB-254 was designed to harm TGD individuals, simply because they are different. One MHP said that SB-254 “doesn’t help clients meet their goals related to beneficence in any way,” underscoring the belief that this law is antithetical to their ethical duties. 

In terms of beneficence as a professional obligation, MHPs suggested that helping clients achieve their goals and improve their quality of life was doing good. MHPs noted that their duty to do what is best for their TGD clients included providing gender-affirming care. In some cases, doing good meant facilitating access to medical care such as gender-affirming surgery, puberty blockers, or hormone therapy. MHPs described how providing access to GAMC promoted emotional and psychological health by allowing clients to align their physical and psychological identities. They felt that SB-254’s restrictions on GAMC created barriers to necessary medical care. As one MHP noted, “It is my role as a social worker to advocate and support clients and provide them with the appropriate resources and respect their dignity and differences. This bill is more about denying that.”

MHPs expressed the importance of helping TGD clients live as their authentic selves, which aligns with the principle of beneficence. One MHP noted, “The only thing that causes harm to them is having others doubt who they are as authentic to themselves… it feels like our hands are tied with how much we can help.” This highlights how MHPs felt that SB-254 impeded their ability to affirm their clients’ identities and contribute to their psychosocial wellbeing. 

Regarding the principle of nonmaleficence, MHPs noted that SB-254 causes harm by preventing TGD individuals from being their true selves. One MHP explained, “What’s ethical to me is not doing the client any harm, and if I’m persuading them out of something that they feel they really need, then that’s harmful to them.” Several MHPs noted that GAMC is an evidence-based intervention that improves mental health outcomes, while denying access to GAMC leads to increased distress, depression, and suicidality. In particular, they noted that without access to appropriate GAMC, individuals with gender dysphoria may experience more chronic mental health challenges, negatively affecting their ability to go to school, maintain employment, and function socially.

Several MHPs highlighted the life-saving potential of GAMC. One MHP suggested that GAMC “turns life into a life worth living,” emphasizing that access to GAMC can improve quality of life while reducing the risks of suicide and other mental health challenges. They further explained that by denying GAMC, the law reinforces the public’s doubt about the authenticity of TGD identities, exacerbating discrimination and the mental health struggles of TGD individuals. 

Some MHPs expressed concern that they might cause clients harm if they provided “the wrong advice.” For instance, MHPs did not want to put clients in legal peril by suggesting that they do something that might contravene SB-254. Other MHPs expressed fear of legal consequences for facilitating access to GAMC. One MHP admitted, “I think I got scared thinking, ‘Oh, I can have my license taken away if I’m doing whatever with transgender people’.” Some MHPs were over-complying with the law, restricting their practice in ways that were not specifically prohibited by SB-254. For instance, some MHPs expressed concerns about assisting a client to access GAMC out of state, even though SB-254 did not specifically prohibit this. Several MHPs noted that they were uncertain about what SB-254 prohibited, so they limited their services for TGD individuals to avoid legal troubles.

Although proponents of SB-254 argue that GAMC is particularly harmful to minors, MHPs noted that GAMC is not just helpful for some TGD minors, but also life-saving, reducing the risks of anxiety, depression, and suicide. MHPs described how denying access to GAMC had negative impacts beyond the individual’s psychological well-being. For instance, they noted how minors with gender dysphoria might have greater difficulty with school, leading to poor academic performance or dropout. Greater risks of mental health issues could also have a negative impact on the whole family and the community. In the words of one MHP:

I’ve seen just first-hand how severe gender dysphoria can affect somebody’s functioning and… their ability to work. So, if they’re not able to go do that [finish school] as teenagers… it’s just going to get worse… they end up developing chronic depression.

MHPs noted that delaying GAMC for minors could also have negative long-term effects. For individuals assigned male at birth, hormone blockers can suppress growth of facial hair, deepening of the voice, and development of an Adam’s apple. As one MHP said, “13 to 18 is very vital for puberty… there are some changes that are irreversible if you don’t get access [to hormone blockers].” For individuals assigned female at birth, hormone blockers can suppress breast development, menstruation, and hip widening. Without these interventions, TGD minors may experience heightened dysphoria not only during adolescence, but also throughout their lives. One MHP said that he had asked adult clients if they wish they had access to GAMC earlier during adolescence. He said a typical response was, “Absolutely, I would’ve killed to have that done.”

MHPs noted widespread misconceptions among legislators about GAMC, particularly regarding irreversible surgeries for minors. They emphasized that such surgeries are exceedingly rare and typically follow comprehensive assessments and significant social transition periods. MHPs also noted that most GAMC surgeons do not provide such surgery for minors.

MHPs addressed concerns that GAMC could have negative effects for people who later regretted having GAMC. They noted more common interventions, such as hormone blockers, are reversible upon discontinuation of the blockers. Some surgeries can also be reversed. MHPs noted that although GAMC entailed certain risks (including regret), the benefits of GAMC outweighed those risks. One MHP suggested that—for adults—the success rate of gender-affirming surgery was more than 95%, which they noted was much higher than for several other types of surgeries. The MHP further explained that even though an individual might regret GAMC later, it may have been appropriate to help their mental health at the time they received such care.

Some MPHs suggested that SB-254 does not necessarily stop people from accessing GAMC. They noted that clients will often look to alternatives, some of which may be unsafe and cause more harm. For instance, they provided examples of clients purchasing hormones from the gray market. The risks of purchasing hormones from the gray market include the risk of criminal charges. Also, hormones purchased from the gray market are not regulated and may be unsafe. Clients may not know what chemicals they are inserting into their bodies. Ordinarily, when clients receive hormone treatment from a licensed local physician—such as an endocrinologist—the physician provides medical oversight, including regular monitoring and dosage adjustments based on the client’s health needs. In contrast, when clients obtain hormones through gray market sources, they may lack appropriate clinical supervision, increasing the risk of improper dosing, adverse side effects, and complications that could otherwise be mitigated through professional care.

For people who have surgery out of state, they may be leaving the state without their family or other support systems. If they return to Florida after surgery, they may not have appropriate medical providers for monitoring and follow-up. SB-254 created dilemmas for MHPs, having to balance the risks of not helping clients access GAMC with the risks entailed by work-arounds such as accessing GAMC outside Florida. Noting the duty to promote good for clients, one MHP explained, “I’m going to do that [facilitate access to GAMC], no matter what the law says, because that’s my code of ethics.”

Autonomy, Self-Determination, and Informed Consent

Most MHPs suggested that SB-254 conflicted with their professional values concerning client autonomy. They explained that a person’s fundamental rights to self-determination, autonomy, and control over their own bodies meant that they should have the right to choose whether to pursue GAMC procedures. Respecting client autonomy meant MHPs should “meet people where they are.” As one MHP said, “Ethically, I feel like if we’re not honoring what the individual feels is right for them, then we’re doing them a disservice.”

Most MHPs supported the notion that adults should have full rights to make GAMC decisions based on informed and voluntary consent. One MHP suggested that GAMC was never appropriate, even for adults. She suggested that someone identifying as TGD should accept their sex and not try to change it. Another MHP contended that denying TGD adults the right to make their own medical decisions was akin to treating them as lacking mental capacity, “that they’re sick or defective.” The other MHPs suggested that denying TGD clients control over decisions affecting their bodies was discriminatory. They highlighted medical procedures that are risker than GAMC, noting that the law still allows people to choose those procedures. One MHP opined that laws criminalizing GAMC were “pre-empting the patient before they come in… As they come forward, this person’s story is now illegal, immoral.” Another added, “It feels judgy… we’re not listening to what people need and want.” MHPs viewed SB-254 as paternalistic and stigmatizing, particularly for capable clients who had thoughtfully considered their choices.

For minors, most MHPs suggested that they should be allowed to access GAMC, provided they have parental consent. In the words of one MHP, “With gender-affirming care, [government is] saying that parents don’t get to decide. …it doesn’t make sense.” Two MHPs expressed reservations about GAMC for minors, even with parental consent, citing concerns that GAMC procedures are irreversible. These MHPs suggested that minors should wait until they are 18 before gaining the right to decide about GAMC. Other MHPs emphasized the importance of allowing people under 18 to have a say in their care, acknowledging their ability to understand whether GAMC was in their best interests.

Among MHPs who supported self-determination regarding access to GAMC, many stressed the importance of fully informed consent. They noted that informed consent should be a collaborative process between the patient, physician, mental health professional, and, for minors, their parents or guardians. MHPs underscored the need for taking time with clients to ensure they fully grasp the implications of GAMC. MHPs described the importance of helping clients make decisions for themselves, supporting their autonomy. One MHP explained, “We’re responsible for helping clients weigh the risks and the benefits of every decision that we try to help them [sic]. We don’t make decisions for them.” MHPs emphasized the need for evidence-based assessments to inform GAMC decisions. Some MHPs highlighted the importance of not coercing or manipulating clients into having GAMC. They noted that MHPs should assess whether clients are ambivalent about GAMC, so as not to rush them into making decisions. They also described the importance of full mental health assessments to ensure a client’s emotional readiness for GAMC.

In terms of supporting minors’ self-determination, one MHP suggested that GAMC could be considered as an emergency medical service due to the urgency of addressing risks such as anxiety, depression, and suicidality. This perspective underscored the necessity of timely intervention, as delays could exacerbate mental health challenges. MHPs explained that many TGD youths are capable of understanding GAMC, particularly with MHPs and physicians helping them learn what GAMC entails, its intended effects, potential side-effects, and how their bodies and lives may change.

Several MHPs contended that government should not be making medical decisions for people. An MHP shared, “I just had a hip replacement. I didn’t go see the governor to say, ‘Hey, you think I need a hip replacement?’ No, I went to an orthopedic surgeon, not a politician.” For GAMC decisions, MHPs emphasized the importance of working with experts in gender-affirming mental health, endocrinology, and surgery. They also emphasized that clients should not be pressured into making decisions. Clients need time to process issues, as well as time to make social transitions before having medical procedures. 

Commitment to Responsible Practice

Several MHPs emphasized their commitment to practice in a responsible manner when serving clients who needed or requested GAMC. They identified key strategies for practicing responsible use of GAMC: conducting thorough assessments with TGD clients, not rushing into transitions with clients, adhering to evidence-based standards of care, staying within their areas of competence, and openly addressing the risks and benefits of GAMC. While their commitment to responsible practice predated SB-254, several MHPs expressed concerns that SB-254 was based on political or religious factors, rather than “solid research” and evidence-based reasoning. They wanted to correct misunderstandings about GAMC and demonstrate that most professionals adhered to responsible, evidence-based processes. They emphasized that following evidence-based standards was critical to upholding GAMC’s legitimacy and safety.

MHPs noted that clients underwent in-depth, individualized mental health and medical evaluations before initiating social or medical transitions. Although some MHPs noted instances where certain professionals were not providing sufficient evaluations—or were rushing into transitions with clients—most suggested that these types of problems were rare or that they had not witnessed any examples of clients being rushed into transitions. One MHP addressed a common misconception among SB-254’s proponents that a minor can simply say, “I’m trans,” and then immediately receive hormones or surgery. The MHP explained, 

I do a full-scale assessment… We kind of push through the “Don’t just tell me what you think I want to hear to write you a letter [for GAMC]. We’re not going to do that. I want to get to know you and really see where you’re coming from and doing this full evaluation…” It could take 6 months. It could take more.

MHPs emphasized that responsible GAMC begins with the client’s goals, and then exploring which forms of care are most appropriate. Responsible care eschews pressuring clients into medical transitions.

MHPs noted that their evaluation processes were guided by evidence-based standards, particularly those of the World Professional Association for Transgender Health (Colman et al., 2022). Some MHPs expressed frustration with insurance companies that imposed requirements beyond evidence-based standards, such as requiring letters from two MHPs, when just one was necessary. Further, they noted that while version 7 of the WPATH standards recommended specific waiting periods before certain GAMC procedures could be performed (e.g., 12 months of continuous hormone therapy before surgery), version 8 (enacted in 2022) suggests a more individualized approach rather than fixed waiting periods. While waiting periods allow for thorough evaluations and ensuring that clients are mentally ready, MHPs suggested prolonged treatment delays can exacerbate anxiety, depression, or mental distress.

MHPs explained that their commitment to responsible GAMC meant considering potential benefits and risks of GAMC, aligning with the principles of beneficence and nonmaleficence. One risk is that some clients may later regret transitions and seek to detransition. To address this risk, some MHPs noted the importance of completing a full assessment without rushing into transitions, and particularly, not rushing into medical transitions. As one MHP noted, “We assess… We can’t give a hormone blocker in five seconds… so it’s a slow process. We’re not giving medication when we first meet them. No one does that.” Another MHP emphasized the value of learning from clients who experienced regret to improve their evaluation and helping processes for future clients.

MHPs noted the importance of helping clients understand the side effects of particular GAMC procedures during the informed consent process. For minors, some MHPs suggested that general protocols do not support irreversible gender-affirming surgeries, such as ones that could result in infertility. MHPs emphasized that gender-affirming care does not mean rushing people into surgery or hormone treatments. One MHP explained, “Gender-affirming care can be as simple as me saying to you, ‘What are your pronouns?’ And then, I use the ones you give me… From a narrative therapy perspective, I’m embracing your narrative in a way that’s syntonic to you, to join with you, to understand where you are.”

In contrast to other MHPs, one MHP suggested that the restrictions in SB-254 included “medically sound” components. He supported the ban on GAMC for minors, particularly regarding irreversible medical procedures. He also believed that it was appropriate to require adults to have in-person meetings with medical professionals before initiating hormone therapy. Other MHPs disagreed, noting that many medications are routinely prescribed through telehealth. They believed that such requirements were medically unnecessary—creating barriers to care, particularly for people in smaller and remote communities.

Several MHPs acknowledged the need for further research to enhance responsible use of GAMC. In particular, they noted the importance of research on the long-term effects of puberty blockers and hormone therapies for minors. Others suggested the use of multidisciplinary consultation teams and individualized evaluations to determine whether GAMC is appropriate for particular clients. MHPs noted the importance of having sufficient knowledge and training to work with TGD clients. They stressed the ethics of professional competence and staying within one’s scope of practice and areas of expertise. For example, one MHP explained that while she could provide a mental health assessment, she referred clients to endocrinologists for medical evaluations for hormone therapy. While there were some differences in opinions about the use of GAMC—particularly for minors—there was broad consensus that GAMC requires a thoughtful, collaborative approach that prioritizes evidence-based practice and individualized care.

Ethical-Legal Conflicts

Several MHPs reported experiencing ethical tension or anguish due to conflicts between their professional ethical duties and the legal restraints on GAMC imposed by SB-284. In particular, they highlighted their duty to provide access to medically necessary services in light of barriers created by SB-254. Some MHPs noted that, ultimately, they would follow the law and try to work within it. Others noted that they would prioritize their clients’ welfare, advocating for what their clients wanted and needed, despite the law. As one MHP noted, “First and foremost, our duty is to the client and to our code of ethics… I’d suggest practicing as usual.” While some MHPs suggested that working under SB-285 was morally distressing, others suggested that they were not experiencing significant distress in relation to how this law was affecting their practice. One MHP reported that she used supervision, exercise, and other self-care strategies to help mitigate the ethical distress she was experiencing.

A primary source of moral distress related to threats to MHP’s licensure and livelihood. Several MHPs noted that while they wanted to do what was right for their clients, they were also concerned about putting their practice in jeopardy. As one noted, “It’s been challenging and uncomfortable… in multiple scenarios in the last year.” Another MHP shared:

 The reason I became a social worker is because I love to be ethical… Unconditional positive regard for every human, and this [law] feels completely incongruous to that. It feels judgy… it feels… that there are external forces telling clients what their mental health and what their goals should be… that doesn’t feel person-centered.

Various MHPs expressed uncertainty about what SB-254 and other Florida laws required with respect to GAMC. One MHP wondered whether they were required to report parents for child abuse if they pursued GAMC for their children. Although a child abuse provision was discussed when SB-254 was being debated, this provision was not adopted. Some MHPs noted that they were confused about what SB-254 required in terms of documentation for GAMC. Others noted that there was a difference between what SB-254 legally required, and what was required for clinically good care. One MHP suggested that the law should not require multiple mental health evaluations for all clients, but rather, allow the physician to determine what types of evaluations were required for each client. MHPs noted that MHPs and physicians tended to follow the laws regarding whether certain types of evaluations and blood tests were required, even if they were not medically indicated.

Some MHPs indicated that SB-254 may raise more difficult ethical issues for physicians than for MHPs. SB-254 does not specifically prohibit MHPs from providing gender-affirming therapy. Since it does restrict the use of puberty blockers, hormone therapies, and gender-affirming surgeries, however, physicians may face challenging issues when the law prohibits them from providing such services to clients who need them. One MHP stated:

I am not providing surgery. So, there’s a lot here [in SB-254] that doesn’t really apply to my type of practice… affirmative care for somebody who’s like a clinical social worker… I’m not touching anybody. A lot of what’s been designed [in SB-254] is aimed at direct providers who provide physiological care.

One MHP said he would tell clients, “Since I don’t have the power to change the bill… we’re going to find ways around this. We’ll find ways to get you the care that you need.” Some MHPs described how they could refer clients out of state if SB-254 prevented them from accessing GAMC within Florida. MHPs noted that people in financially vulnerable situations faced the greatest barriers to access GAMC. First, SB-254 prohibited Medicaid funding for GAMC. Second, people who could afford to pay for medical care and travel out of state could simply access GAMC out of state, whereas people with limited financial means could not afford the high costs of gender-affirming surgery, hormone treatments, and/or travel. To address these issues, MHPs connected clients with organizations that provided funding or assisted with travel to allow clients to access out-of-state GAMC. Private practice MHPs may have felt freer than agency-based practitioners to refer clients out of state. One MHP noted that her agency told her not to refer clients out of state because there could be liability if the client experienced negative outcomes. The agency wanted to avoid potential malpractice lawsuits. Some MHPs felt their employers were over-complying with SB-254, preventing both MHPs and physicians from providing certain types of help that were not specifically prohibited.

Honesty and Transparency

MHPs noted that SB-254 raised ethical issues in relation to honesty (being truthful) and transparency (fully disclosing relevant information). MHPs emphasized the importance of providing clients with truthful information about GAMC, including its risks and benefits, and the effects of SB-254’s restrictions on access to GAMC. MHPs used honesty and transparency to foster trust with clients and to promote informed consent. As one MHP noted, “Part of our responsibility is around being transparent and truthful…. being able to encourage our clients from a place of as much objectivity as possible when possible, and not deceiving or misleading people.” However, MHPs also faced challenges when being honest and fully disclosing information could put clients at risk.

One MHP suggested that SB-254’s restrictions are not based on honest information, but rather inaccurate information and fear mongering. She noted the importance of being transparent and objective when discussing the risks and benefits of particular GAMC procedures, including whether they are appropriate for a particular client. “Fear mongering is like the opposite of veracity.” Other MHPs described the importance of letting clients know about SB-254’s restrictions at the outset of services so clients would know up front about whether they may be restricted from accessing GAMC.

Some MHPs said SB-254’s restrictions could lead clients to dishonesty. In particular, they noted that some people were resorting to gray market hormones because they could not get them in Florida. This trend was especially evident among TGD youth, who became subject to SB-254’s blanket prohibition on GAMC for minors. TGD adults enrolled in Medicaid were also impacted. Because Medicaid no longer covered gender-affirming hormone therapies, some Medicaid recipients were prompted to seek more affordable alternatives through unregulated channels. In addition to medical risks associated with unsupervised hormone use, some MHPs noted that purchasing gray market hormones could expose clients to criminal liability

Issues of honesty and transparency also arose in discussions about the possibility of future discrimination. MHPs noted that some clients and parents expressed concerns about how information about gender concerns or requests for GAMC might be used against TGD individuals. MHPs said they engaged clients in frank discussions, including the possibility that the government could pass future legislation targeting TGD individuals in different ways. For instance, would professionals have to report parents to child protection services if they sought GAMC for their children, would future laws prohibit private insurance from covering TGD individuals, could TGD students or adults be banned from sports, or could there be other forms of discrimination aimed at TGD individuals?

Some MHPs noted that, since SB-254’s passage, they were more reluctant to provide clients with a diagnosis of gender dysphoria or document that they are TGD (Barsky & Simpson, 2025). Given the state legislature’s support for anti-trans measures in SB-254, they expressed concerns about putting clients at risk simply by documenting conditions that could be used for discrimination against them. Some MHPs said they might refrain from documenting a client’s gender identity, gender dysphoria, or requests for GAMC to avoid the possibility that this information could be used against themselves or their clients. For instance, they might document a client’s mental health concerns in general terms, without noting issues particular to gender identity or dysphoria. If they assisted a client access GAMC outside Florida, they might refrain from documenting their referrals. One MHP said she used a client’s initials rather than the client’s they/them pronouns, disguising their gender identity so as not to set them up for discrimination. Another MHP described his cautiousness about documentation to avoid harm as staying “under the radar.”

Although some MHPs highlighted concerns about discrimination by state entities, one MHP focused on the possibility of discrimination by insurance companies:

[I] just don’t trust that they [insurance companies] won’t hold it against my clients in the future, and I want my clients to feel safe… and know whatever diagnose I give them. So, if they don’t feel comfortable with that [documenting gender dysphoria], I’d rather respect that.

Concerns about discrimination meant that MHPs had to balance the ethics of honesty and transparency in their record-keeping with the duty to protect clients from harm. One MHP noted that his primary duty was to his clients and that he would continue to provide service as usual, but that it was important to “be aware of documentation” that might put a client at risk. Another MHP said her first obligation was “to do no harm.” She said she would not document gender dysphoria for a client without having a frank conversation with them about the possible risks of having this information in their records. To ensure that clients were aware of possible risks, MHPs discussed who might have access to the information (e.g., insurance, government) and how the information might be used.

Privacy and Confidentiality

While MHPs have a duty to protect the privacy and confidentiality of all clients, this responsibility becomes more pronounced when working with TGD clients seeking access to GAMC. As noted earlier, MHPs raised concerns that TGD clients might face discrimination if the government or insurance companies became aware of their gender identities or interest in GAMC. MHPs noted a marked increase in incidents of transphobic harassment and discrimination following the introduction of SB-254 in the Florida state legislature. MHPs also suggested that some TGD clients—minors and adults—preferred to keep their gender identities and transition plans private, sometimes even from their parents or other family members.

MHPs noted that one way to protect client privacy was to limit what was documented in their client records. This was particularly important for minors because their parents might have access to their records. Although MHPs respected the rights of their clients to keep their gender identity hidden from their parents, this could cause conflicts if the parents later found out that the MHP was withholding information about their child. SB-254 came into effect one year after the Parental Rights in Education Act (Florida House Bill 1557, 2022), which requires school personnel to inform parents if their children were receiving mental health counseling. One MHP noted that TGD students would be outed to their parents if they discussed their gender identity with their school counselors; however, she received referrals from schools to help TGD clients who had not come out to their parents. Although the MHP could provide a safe place for the student to talk with them, this created a potential conflict with the parents since she could not share the details of her work with their child.

MHPs noted that many parents wanted to protect their TGD children from harassment and discrimination. One MHP noted, “Parents are very worried about bringing their children to therapy, that it is going to put them on the radar of the state.” This MHP noted that some parents chose to pay fees for services rather than bill insurance companies, so as not to alert insurance companies or the state about why they were seeking services. To ensure privacy, another MHP said she offered appointments in evenings and on weekends, when few people were around her office and it was less likely that friends or acquaintances would find out that the child was receiving mental health services. Parents often asked questions about who would have access to information about the child’s gender identity and therapy. The MHP would note that some information would be sent to their health insurance company. Although insurance companies are not supposed to discriminate based on gender, the MHP did discuss the possibility of changes in the laws that would allow a diagnosis of gender dysphoria to be seen as a pre-existing condition, affecting the child’s ability to obtain insurance coverage in the future. When parents preferred not to have a diagnosis on the child’s records, the MHP would not document such a diagnosis.

Respecting Dignity and Worth of the Person

MHPs noted that the essence of gender-affirming care was respecting the dignity and worth of the person. This included respecting the client’s truth, validating their narrative, and supporting their needs and wishes. MHPs provided examples of using affirmative language with clients, including use of names and pronouns that respected the client’s gender identity. Several MHPs suggested that SB-254 did not show respect for the dignity and worth of the person as it prevented them from making self-determined choices about GAMC. Some MHPs said that even if they were able to help clients access appropriate care by “going under the radar” and limiting their documentation of services, they were not able to fully affirm their clients’ authentic genders due to SB-254’s impact.

MHPs emphasized the importance of offering empathy and validation to TGD clients, particularly in the wake of the restrictive measures imposed by SB-254. They described how this law specifically targets TGD individuals, barring many of them from accessing GAMC and reinforcing harmful messages that suggest TGD people are “less than human, or broken, or defective.” One MHP highlighted the profound impact of this message, stating that the law implies, “This person’s story isn’t valid.” By restricting access to GAMC, SB-254 denies TGD clients the opportunity to align their physical selves with their psychological identities, creating significant barriers to living authentically. Furthermore, this misalignment exposes TGD individuals to heightened risks of discrimination and stigmatization, exacerbating the challenges they face in achieving self-acceptance and societal equity. For MHPs, these barriers not only compromise their clients’ mental health but also contradict foundational ethical principles of respect, dignity, and the affirmation of individual identities.

Limitations

The primary limitations of this study relate to the sample and timing of data collection. First, the studied relied on a convenience sample of 17 mental health professionals from Florida, limiting the generalizability or transferability of the findings (Denzin & Lincoln, 2017). While the sample offered valuable insights, it primarily represented MHPs physically located in South Florida, meaning underrepresentation of perspectives from northern and central Florida. This limitation is partially mitigated by the fact that many participants practiced with clients remotely and across Florida, meaning that they were familiar with regional differences such as disparities in access to services in smaller and more remote communities.

A second limitation of this research is that it captured MHPs’ impressions of SB-254’s impact at a particular point in time. The interviews took place 6 to 11 months after SB-254 took effect. Since the data collection, there have been a number of changes, including changes in requirements from insurance companies, temporary injunctions from certain courts, the Supreme Court’s decision to uphold certain types of legislative bans on GAMC, and departmental guidelines to clarify procedures for consent and the necessity for psychological evaluations. Notably, the Joint Committee of the Board of Medicine and Board of Osteopathic Medicine determined that psychological evaluations for hormone replacement therapies would no longer be required, providing discretion to endocrinologists in determining what types of evaluations should be used (Maulden & Shalom, 2023). Given the dynamic nature of SB-254’s implementation, the law’s impacts on TGD individuals and their service providers is likely to evolve. Future studies should take these ongoing changes into account, providing a more comprehensive understanding the long-term impacts of laws that restrict or ban access to GAMC.

Conclusion

In the aftermath of SB-254’s passage, MHPs serving TGD clients in Florida faced a range of ethical challenges in helping those who wanted assistance with GAMC. The legislation’s restrictions on GAMC not only hindered MHPs’ ability to provide needed support but also created substantial ethical-legal conflicts. This study found that while 16 of 17 MHPs viewed GAMC as an effective intervention, SB-254 imposed barriers to accessing this care—particularly for minors, as well as for adults reliant on Medicaid. Many MHPs had to navigate complex ethical dilemmas, including whether to refer clients out of state or find alternative resources to maintain their clients’ well-being. In some cases, this meant helping clients detransition because they could no longer afford hormone therapy (Turban et al., 2022). SB-254 also impacted the practice environment, contributing to increased confusion, fear, and anxiety among MHPs, their clients, and family members (Barsky, 2024).

MHPs were sensitive to the political discourse and broader ramifications surrounding the passage of anti-GAMC laws. They noted that TGD individuals were facing greater levels of harassment and discrimination, and that some were considering relocating from Florida (Barsky, 2024). MHPs were also aware of critiques of GAMC, including suggestions that GAMC was ineffective and harmful. They emphasized their commitment to the responsible use of GAMC, highlighting ways that they conducted comprehensive assessments, relied on evidence-based practice standards, and took extensive time working with TGD clients, before determining whether or when GAMC might be appropriate for them. As the WPATH Standards indicate, the purpose of gender-affirming care is to provide “safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment” (Coleman et al., 2022). MHPs in this study recognized that GAMC entailed certain risks, so they highlighted the importance of following research-based protocols for GAMC and advocated against politicizing gender-affirming care, including medical interventions. They also noted the importance of interprofessional collaboration and using a strategic, phased approach as safeguards to ensure that gender-affirming care was being provided in appropriate situations and in an appropriate manner (Taylor et al., 2025), as emphasized within the ethical guidelines of their professions.

MHPs underscored their commitment to ethical principles of autonomy, beneficence, nonmaleficence, and justice, often advocating for clients’ rights despite legal constraints. MHPs also stressed the importance of maintaining honesty, transparency, and client confidentiality, especially in light of potential discrimination and legal repercussions. The findings highlight the broader ramifications of politicizing healthcare, demonstrating how such policies can exacerbate stigma, limit access to care, and negatively affect the mental health and safety of TGD individuals, thus underscoring the importance of ethical practice. Given the stigma, discrimination, and restrictions on health care faced by TGD individuals, MHPs have an ethical responsibility to advocate for more inclusive and respectful government policies, laws, and treatment for the TGD community (APA, 2017; NASW, 2021; Singh, & Burnes, 2010).

Future research should explore the long-term impacts of GAMC restrictions, particularly as policies evolve and legal challenges unfold. Policymakers and healthcare professionals must collaborate to ensure that laws and regulations are informed by evidence-based practices rather than political influences. It will also be important to study how MHPs adapt to legislative restrictions on GAMC and how they balance their ethical and legal obligations to TGD clients.

Declaration of Interest

The authors report there are no competing interests to declare.

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Consent and IRB Approval

1. Although the term “sex reassignment” is used in this legislation, it is considered pejorative by members of the TGD community and their health care providers. When individuals have gender-affirming medical care, they are not changing their sex, but rather, affirming their gender identity (Coleman et al., 2022).
2. This provision means that nurse practitioners, pharmacists, and physician’s assistants can no longer prescribe or administer hormone therapies as part of gender-affirming medical care.