Transgender Ohioans face uncertain futures under new gender-affirming care restrictions

Transgender people face an uncertain future in Ohio under a new law banning gender-affirming health care for minors and administrative rules that heavily restrict access to care for adults.

The state’s GOP-controlled Legislature on Wednesday overrode Republican Gov. Mike DeWine’s veto of House Bill 68, allowing a ban on gender-affirming health care for transgender minors to take effect in 90 days. The law also prevents transgender student-athletes from competing on sports teams consistent with their gender identity.

Beyond the Legislature, a set of draft rules issued earlier this month by Ohio’s Department of Health and Department of Mental Health and Addiction Services is set to make the state one of the nation’s most restrictive for adults seeking access to gender-affirming care.

The rules would bar hospitals and health care facilities in the state from administering care to transgender individuals of any age, unless a treatment plan is established by a team of psychiatrists, endocrinologists and medical ethicists.

Patients younger than 21 would have to receive at least six months of mental health counseling before they can receive gender-affirming medication or surgery, according to the proposed regulations, and providers would be barred from referring minors to out-of-state facilities for surgery.

Gender-affirming surgeries, which are generally not recommended for trans youth younger than 18, are illegal for minors in Ohio under an executive order signed Jan. 5 by DeWine.

The proposed administrative rules have been criticized as harmful and unnecessary by medical professionals and LGBTQ rights advocates. The American Civil Liberties Union and the ACLU of Ohio said the rules could amount to a “de facto ban” on care in the state.

The rules are also patently inconsistent with standards of care set by transgender health care organizations including the World Professional Association of Transgender Health, said Dr. Adarsh Krishen, chief medical officer of Planned Parenthood of Greater Ohio.

“There’s some very clear, well-vetted, well-studied guidelines that are the cornerstone of providing gender-affirming care, and these proposed requirements do not align with that at all,” Krishen said.

Gender-affirming health care for both transgender minors and adults is considered safe, effective and medically necessary by every major medical organization, though not every trans person chooses to medically transition or has access to care.

Krishen said he is concerned about how Ohio’s draft rules will impact trans adults who have medically transitioned so their bodies no longer produce hormones on their own. He also worries how the proposed restrictions will impact smaller or independent clinics that cater to rural populations and may not be equipped financially to hire specialists like medical ethicists, who are commonly employed by large hospital systems.

“The expense is either going to have to be passed on to the patient or absorbed by the clinics,” he said. “Clinics that don’t have the resources to weather the storm — or find the administrative burden too difficult — will just stop providing this care.”

Cam Ogden, the 23-year-old founder of Trans Allies of Ohio, a statewide advocacy organization, said the clinic where she is prescribed estrogen may be one of several forced to close if the rules go into effect as written.

“I’m not confident in my ability to maintain continuity of care if I only get my care from Ohio,” she said, “so I’m probably looking at driving to a different state to go to my health care appointments.”

Ogden has strong family ties to central Ohio, where she currently lives, and isn’t “going to be leaving or moving anytime soon,” she said.

“I’ll probably be driving three hours or so to get my medications,” she said. None of the five states that share a border with Ohio — Michigan, Indiana, Kentucky, West Virginia and Pennsylvania — restrict access to gender-affirming health care for adults, though some have enacted laws banning such care for minors.

Jacob Nash, a transgender activist and consultant in the greater Cleveland area, said Ohio’s draft rules are a huge step back for trans people in the state. The proposed restrictions are reminiscent of limitations placed on gender-affirming care when Nash first started his medical transition in the mid-90s, he said, when he had to visit several doctors to receive hormones.

“I transitioned 25 years ago,” said Nash, 59. “I feel like I’m back where I began.”

“Some of us older trans folks know what it’s like to have to cross state lines to get the care we need,” said Nash, who traveled from Massachusetts to Connecticut to get his medication when he started transitioning.

Leaving Ohio in any capacity, either just temporarily or permanently, isn’t a feasible option for many trans people in the state, said Dara Adkinson, board secretary for the advocacy group TransOhio.

Dozens of transgender adults and families with transgender children have contacted the group about receiving emergency relocation funding, Adkinson said, citing both the proposed administrative rules and House Bill 68.

Adkinson, who uses they/them pronouns, has their reservations about the draft rules, including a requirement that data collected by the state Health Department on trans people be delivered to the state Legislature.

“Why the statehouse would ever want or need that information is a particular point of concern for sure,” they said.

Adkinson said they also worry how the effects of the rules, once they are finalized and implemented, will be compounded with those of House Bill 68. So does Nick Zingarelli, a Cincinnati attorney.

Zingarelli, 44, said he’s unsure of what the future will look like for his teenage daughter, who came out as transgender in December 2020.

Zingarelli, his wife and their daughter moved to Ohio from Missouri in spring 2022, in part because of restrictive bills advanced by Missouri’s Republican-dominated Legislature that targeted transgender youth. The state’s GOP Gov. Mike Parson in June signed legislation limiting access to gender-affirming health care and preventing transgender student-athletes from competing on sports teams consistent with their gender identity.

“We view [Ohio] as being a more moderate and more understanding place,” said Zingarelli, who is originally from Columbus. “We were hoping that we would not have to face something like House Bill 68.”

Ohio’s law makes an exception for minors who were already receiving care before its effective date, which includes Zingarelli’s daughter. To protect her privacy, The Hill is not publishing Zingarelli’s daughter’s name.

But Zingarelli and his wife are still somewhat uncertain that their daughter’s health care will remain untouched by House Bill 68. Similar “grandfather” clauses added to other states’ gender-affirming care bans have confused health care providers and raised concerns about liability, leading to overcompliance in some cases.

Lawsuits filed in Missouri and North Dakota allege transgender minors not subject to new laws banning gender-affirming care have been denied treatment. In Nebraska, pharmacists are reportedly refusing to refill prescriptions issued to transgender minors considered exempt from the state’s new restrictions on gender-affirming care, a state senator wrote in an October letter to Nebraska’s chief medical officer.

“There is a concern that health care providers could be regulated to a point that they just say ‘it is no longer feasible for us to be able to offer the care — that the government has now made it impossible for us to be able to do this,’” Zingarelli said. “I do have concerns about that.”

Leaving Ohio is not currently an option Zingarelli and his family are considering, but “we will do whatever we have to do in order to get our child the care that she needs,” he said.

In the meantime, “we’re fighting like hell to stay in our home,” he said.