All products are independently selected by our editors. If you buy something, we may earn an affiliate commission.
Content Warning: This story contains a discussion of suicide.
When Cass Crawford first came out as nonbinary in July 2019 to their parents, their mom refused to accept them. “I came out as nonbinary, and my mom told me that was not a real thing,” Cass remembered. “And that I would always be a girl. She refused to accept my name change.” Looking back at the moment, Cass's mom Heather Crawford said she told Cass, “everything you’re not supposed to say.”
Cass, who’s now 16 and is a transgender man, struggled greatly with anxiety and depression in the months after they came out to their parents. He expressed how hurtful and confusing the rejection was. As they coped with their mom’s rejection, Cass’s home state of Texas was also introducing legislation restricting trans rights.
Three months later, Crawford remembers arriving home after work on Oct. 28, 2019 and finding that Cass had attempted suicide. They had written a suicide note in blue glitter pen.
Cass spent 12 hours in the hospital and 13 days in an inpatient psychiatric facility until they stabilized. For Crawford, that was a wakeup call. While Cass was in the hospital, his parents made the decision to help Cass socially transition, calling them by their chosen name and pronouns. Doing so helped improve Cass’s mental health over time.
Still, Crawford said Cass continued to struggle with gender dysphoria, compounded by their inability to access gender affirming healthcare (such as top surgery) and an increasingly hostile political environment in Texas. The barriers to Cass’s care were multi-factored. More recently, Crawford feared if she helped Cass get top surgery in Texas it would spur a child abuse investigation from the Department of Family and Protective Services. Second, Crawford was worried that her insurance would refuse to cover the surgery. And, Crawford more greatly feared legislation banning gender affirming care would pass.
So, the Crawfords decided to fight. In the years since Cass came out to his parents, anti-trans efforts have become increasingly common in Texas and across the country. Recently many states are attempting to ban trans youth from accessing life-saving treatment like hormone therapy and other gender-affirming care. On Feb. 22, 2022, Texas Gov. Greg Abbott issued a directive to the Texas Department of Family and Protective Services, mandating that the agency investigate families who provide gender-affirming healthcare to their children for child abuse. After Gov. Abbott’s mandate, Crawford read Cass’s suicide letter at the DFPS’s Council Meeting. The state has since been in a legal battle over the order, and is currently banned from such investigations.
“When I'm talking about why it's important to affirm trans children, the best argument I have is that note,” Crawford said, when asked why she testified. “If you screw it up on this one issue, your children are going to die on it.”
Still, anti-trans sentiment in the state continued to build, so the Crawfords decided to relocate to Minnesota in August.
“I still really want to live [in Texas],” Cass said. “I want to be with all my friends. I want everything that's familiar. But also, I'm really scared that if I were there I would be taken away from my family.”
Cass and his family are far from alone in their fight for rights and fear of failing to get them.
The UCLA Williams Institute of Law estimated in June that there are 1.6 million Americans ages 13 and older who identify as transgender — 625,800 of whom live in the South and 102,200 of whom are ages 13 to 17. Across the country, at least 17 states have restricted gender-affirming care — Alabama, Arkansas, Arizona, South Dakota, Tennessee, Utah, Mississippi, Georgia, Kentucky, Iowa, West Virginia, Idaho, Indiana, Florida, Texas, Missouri and North Dakota, though current court injunctions are allowing continued access in Alabama, Arkansas and Texas for now. According to data from the ACLU more than half of states have bills attempting to do so.
While gender-affirming healthcare for minors has become a hotly contested issue both politically and in the media, it’s widely supported in the medical community; the American Academy of Pediatrics, American Medical Association, American Psychiatric Association, Endocrine Society and World Professional Association for Transgender Health have all recommended gender-affirming care for trans youth and condemned any restriction or criminalization of such healthcare.
Still, in an analysis of American Civil Liberty Union data the Washington Post reports that anti-transgender legislation is rising exponentially: 2018 saw 19 bills, 2019 saw 25, 2020 saw 60, 2021 saw 131 and 2022 saw 155. This year, the ACLU reports more than 469 anti-LGBTQ bills, more than a quarter of which that aim to restrict trans healthcare.
As more states target care for trans youth, Republican legislators may not stop there; at least four states have introduced bills that would target young adults up to the ages of 21 or 25 in Oklahoma, South Carolina, Kansas and Virginia. States like Texas, and Oklahoma have filed bills that would block almost all care for minors and adults by prohibiting state funding for treatment, barring health insurance coverage or holding healthcare providers and insurers liable for malpractice suits.
Most recently, Missouri Attorney General Andrew Bailey issued emergency regulation restricting care for trans minors and adults. Effective April 27, trans people of all ages will be required to show three consecutive years of medically documented dysphoria. In order to provide certain gender-affirming care, Missouri healthcare providers must ensure “any psychiatric symptoms from existing mental health comorbidities of the patient have been treated and resolved.” Additionally, providers must determine if patients seeking gender affirming care have autism.
Erin Reed, queer legislative researcher and activist, said after right-wing politicians and lobbyists focused their resources on a single state — namely the 2016 bathroom bill in North Carolina — they changed their strategy to a “shotgun approach,” pushing as many laws in as many states as possible so a few of them can pass each year.
For example, Reed estimates there are at least 11 bills introduced in several other states that are identical or similar to Arkansas’s 2021 SAFE Act, which bans gender-affirming care for minors and puts the doctors who treat them at risk of legal action.
“This is not about consent or ability to consent or about gender affirming care,” said Reed. “It's literally about upholding a patriarchal, gender-based classification system that they have to force everybody to fit within.”
Many of these bills and laws, Reed notes, carve out exceptions for the same kind of care, but for intersex people — something those in the intersex community have pushed back on.
For Cass and many other trans youth, restrictions on gender-affirming care means gender dysphoria is going untreated. The American Psychiatric Association defines gender dysphoria as psychological distress resulting from incongruence between a person’s sex assigned at birth and gender identity. That psychological distress can contribute to depression, anxiety and suicidality.
Bhavik Kumar, MD, MPH, Medical Director for Primary and Trans Care at Planned Parenthood Gulf Coast, said that gender affirming care saves lives.
“When we think about the mental health impacts of dysphoria and the results from folks accessing care and what that means and how much we see improvements in depression and anxiety and suicidality, it is very, very clear. It's not even debatable,” said Dr. Kumar.
The 2015 U.S. Transgender Survey found that 40% of respondents had attempted suicide in their lifetimes. And while the lack of access to gender-affirming care is only one contributing factor to that rate, it does make a difference. In a secondary analysis of the data, USTS researchers found that 8.5% of respondents who wanted but did not receive gender-affirming surgery reported suicide attempts in the year prior. This compared to a 5.1% rate for respondents who wanted and received gender-affirming surgery.
Hormone replacement therapy and puberty blockers can also have positive psychological effects for trans people. Another secondary analysis of the USTS data, published last year in the journal PLOS One, found that trans people who accessed gender-affirming hormones had better mental health outcomes compared to those who wanted and did not receive said care. The study found that this was especially true for those who accessed care between the ages of 14 and 17 compared to those in their adulthood.
For Cass, just knowing that his mom has talked with a gender clinic about getting top surgery in Minnesota is relieving. Their chest is a large source of their gender dysphoria and contributes to self-harm ideation.
In Texas, gender-affirming care is not the only healthcare that can be difficult to access for transgender people assigned female-at-birth.
For trans people capable of pregnancy, access to medical care is heavily legislated in Texas, where abortion is banned except in the case of a life-threatening emergency. And, Chase Strangio, deputy director for transgender justice at the ACLU’s LGBT & HIV Project, believes the attack on transgender healthcare and abortion is part of a larger battle.
“These are entry points into further erosions into our bodily autonomy and our ability to care for our families and our communities,” Strangio said during an Instagram Live.
In many of the states that have restricted gender-affirming care for minors or have introduced bills that would do so, abortion is also banned or restricted.
Pregnancy may increase feelings of gender dysphoria, which can impact mental health. And, trans men (51%) and non-binary people assigned female at birth (58%) report higher rates of sexual assault in comparison with trans women (37%) and non-binary people assigned male at birth (41%), according to the 2015 U.S. Transgender Survey.
The Turnaway Study, a longterm study analyzing the effects of unwanted pregnancy conducted by the Advancing New Standards in Reproductive Health at the University of California San Francisco, recently examined psychological well-being for those denied of abortion. In 2020, Turnaway researchers found that those who were denied an abortion experienced higher levels of anxiety, stress and lower self-esteem from a week to months after trying to get an abortion.
Beyond the fact that anti-abortion and anti-transgender healthcare laws often coincide in the same states, legislators are attempting to use similar tactics to target abortion and gender-affirming care seekers and providers. After the Dobbs decision, Alabama used some language the Supreme Court employed in overturning Roe v. Wade, saying gender-affirming care is also not “deeply rooted in our nation’s history and tradition” in a brief for the 11th Circuit Court of Appeals. Also last year, a legislator in Missouri introduced an amendment to an abortion bill that would allow private citizens to sue anyone who helps a state resident get an abortion outside of that state (it died in committee). Idaho introduced a similar law, which would have criminalized gender-affirming care and made it a life-sentence felony for anyone who helps a minor cross state lines to obtain said care. The bill passed in the house, but died in the senate.
This month, Idaho passed a law criminalizing helping a minor obtain an abortion out-of-state, similar to the bill targeting gender-affirming care that died in the state’s senate. The surge in anti-trans bills (including but not limited to gender-affirming care), already enacted trans healthcare bans, and abortion bans are contributing to a political climate that is proving detrimental to trans youth’s mental health.
Cass said he can’t imagine a long-term future as a young trans person in this country because of the impact on their mental health. And they are not alone — last year in a poll conducted by Morning Consult for the Trevor Project found that 85% of transgender and nonbinary youth report the debates around anti-trans bills have negatively impacted their mental health.
Meg Paceley, Associate Professor at the University of Kansas School of Social Welfare and the co-director of the school’s Center for LGBTQ+ Research and Advocacy, led a qualitative study in a Midwestern state surveying the mental health implications of anti-trans policy and rhetoric and found that for their trans and gender-diverse focus group members, even the proposal of these policies increased depression, suicidality and general distrust.
Paceley said it raises questions for trans youth like, “Who's looking at me? What's going to happen when I go in these spaces?” Adding, that fear contributes to anxiety and depression. And if healthcare bans for people under 18, 21, or 26 do pass, “that's a long time to live without affirming health care that can really, really reduce gender dysphoria and save young people's lives,” Paceley said.
But there is hope, particularly in how the trans community cares for its own.
To counter the negative impact of anti-trans legislation, Paceley said it’s important to tap into community resources, encourage education, and create affirming spaces for queer and trans people. The queer youth they’ve talked to in their research at-large have pointed to the importance of having queer and trans friends, engaging in activism and subverting negative societal expectations. And for young people like Cass, there are increasingly more transgender adults and elders who can offer advice on navigating a hostile political climate, and show that a long life as a trans person isn’t just possible, it’s probable.
For JJ Favela, coming out as a transgender woman has been euphoric. Favela, 24, lives in Tempe, Arizona and started transitioning socially and taking hormone replacement therapy last year. While she hasn’t faced legal barriers to accessing gender-affirming care, she knows the toll of seeing the increase in anti-trans legislation.
“As much pain as living in this political climate has brought me, it can never take away the sheer joy that I feel getting to finally express who I am,” said Favela. “And if you're young and you recognize that, and you're in a hostile environment, you know, I know that there are ways that you can reach out to people and find resources that are there to help you.”
Passing policies at the local and state level, though, remain of highest importance in combatting a harmful political climate. At least eight states and Washington D.C. have recently passed laws and executive orders to protect parents and kids fleeing penalties for seeking gender-affirming care — California, Massachusetts, Connecticut, New Jersey, Colorado, Washington, Minnesota and Illinois (many of these laws also contain protections for abortion providers and patients seeking refuge).
But for those who can’t leave their home states or don’t want to, engaging in activism may be their best bet against these restrictions. Reed said one of the best strategies in pushing back on these laws is having trans people testify before lawmakers and school boards, humanizing the highly politicized issue. Strangio also warned that stopping these bans from passing now is imperative and that those who want to get involved should follow local organizers’ lead.
“Everyone should do everything in their power to prevent bans on health care from passing because they ultimately will be devastating, and they will be difficult to stop in court in the long run, even though we've had tremendous success in the short term,” Strangio said in his livestream.
Since moving to Minnesota, the effect of these laws remain heavy on Cass. And, being separated from their friends hasn’t been easy.
Recently, Cass started attending monthly outings and meetings with a group of trans, gender-expansive and intersex youth in Minneapolis, TIGERRS. And, they’re looking into joining a fencing club — a sport he says is exciting and empowering during matches.
His mom said he will still ask about moving back to Texas, their home state. Because they miss their friends and life in Texas, Cass jokingly tells their mom they can pretend to be a girl and that people don’t have to use the right pronouns. “And every time they say that, I say, ‘the last time you had to do that, you almost died because of it,’” said Crawford.
As a parent, Crawford feels the toll of Texas’s anti-trans policies too.
“I had to ruin their life to save their life,” she said. “And I will never be over that. I will never forget that.”
Let us slide into your DMs. Sign up for the Teen Vogue daily email.
If you or someone you know is going through a crisis, you can contact the National Suicide Prevention Lifeline at 988 or +1 (800) 273-TALK (8255).
