Efforts at the federal level to restrict access to gender-affirming care, particularly for minors, have resulted in growing demand in Colorado from out-of-state families seeking care for their transgender children.
The U.S. Supreme Court in June delivered the latest blow to gender-affirming care access when it allowed states to maintain bans on gender-affirming care for minors. In United States v. Skrmetti, the Supreme Court issued a 6-3 ruling that affirmed a reversal of a lower court finding that restrictions in Tennessee violate the constitutional rights of children seeking puberty blockers and hormones to treat gender dysphoria. The court’s three liberal justices dissented, writing that the court had abandoned transgender children and their families to “political whims.”
The decision was announced less than a week before the third anniversary of the U.S. Supreme Court decision that revoked national protections for another form of reproductive health care, abortion care. Abortion and gender-affirming care are both protected in Colorado but banned in dozens of states.
States like Colorado have seen an increase in demand for abortion care since the 2022 Dobbs decision overturned the constitutional right to abortion. Now the Skrmetti ruling, which sanctioned bans on gender-affirming care for minors in the 27 states where they exist and others that could adopt new restrictions, adds further hostility to an environment in which demand for gender-affirming care for minors in Colorado has accelerated.
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The Trans Continental Pipeline, a group that provides assistance to transgender people hoping to relocate to Colorado and other safe states out of fear of hostile policies, received about 550 requests for help in the first month following the November presidential election.
Jack Teter, vice president of government affairs for Planned Parenthood of the Rocky Mountains, which offers gender-affirming care to adults, said the legal mechanisms to restrict access to gender-affirming care and abortion are similar because, like in the Dobbs decision, the court ruled that “states have the ability to ban this care if they want to.”
But because gender-affirming care isn’t completed in a single appointment like abortion care is, traveling out of state to receive that care is logistically more difficult, particularly for minors.
“Abortion care is usually a one time encounter with a medical provider, and gender-affirming care is lifetime care. I’ve been receiving gender-affirming care for a decade,” Teter said. “So what I am seeing are families who have adolescents, who are living in states that have either already banned this care or have already been experiencing discrimination of their kiddos in school … those families are moving.”
Alex Floyd, health equity director at LGBTQ+ advocacy group One Colorado, said the organization is hearing more and more stories from families who move across state borders to find a safer community for their children who need gender-affirming care, particularly after the November presidential election.
“I met one parent at Erie Pride this year who was just walking through the little pride festival, just crying, because she’s like, ‘We just moved from Florida and I haven’t been in a place that felt so safe and welcoming and so full of visible community for my youth in so many years.’” Floyd said. “We’ve seen this gradually happening over the years as certain states around us have bans, and ever since the election and this new federal administration, I think that has just skyrocketed.”
Making that move “hits every area of your life,” Floyd said. If the parents don’t have remote jobs, they’ll have to find new ones, which could also mean switching health insurance plans that could affect their ability to get gender-affirming care for their children. There is also a big financial toll of moving to another state, and families have to find community in places where they might not know anybody.
“They don’t have that net of support that hopefully they had in a place where maybe they’ve lived for their whole life or for the last 10-15 years,” Floyd said. “It’s an uphill battle, and Colorado is not cheap. Denver especially is not cheap, and so we also see a lot of families are moving here for care, then they’re having to live in more rural parts of the state, where we still have some pretty significant care disparities.”
Colorado has several laws that protect access to both abortion and gender-affirming care. In 2023, the Colorado Legislature passed a shield law to protect people who travel to Colorado for abortion or gender-affirming care from lawsuits and criminal prosecution initiated in other states. It also protects providers and people who assist patients from that prosecution. This year, the Legislature passed a law that prohibits insurance plans from limiting or denying gender-affirming care that a doctor identifies as medically necessary.
Teter said “it will be interesting to see” the impact of the Skrmetti ruling on where LGBTQ+ families decide to live. He said not every family will decide to move out of their home states, but he said he “would expect to see some scale of a migration to states like Colorado and New Mexico.”
“There are trans people in every state in the country, and there has never been a world without trans people, and there never will be,” Teter said. “And just as in the time before gay marriage was legalized nationwide, there were LGBT couples living together, owning homes together, raising children in all 50 states, including states that had marriage bans.”
Teter said it’s hard to imagine that trans folks of all ages wouldn’t consider moving out of a state that bans gender-affirming care for minors, even if it doesn’t affect them personally. He said being in a state that would decide to ban care specifically for transgender people “has an impact on people’s psyche, regardless.”
“This decision is an attack on families,” Teter said of the Skrmetti ruling. “It’s an attack on the ability of families to decide what kind of health care is best for them, and it is so contrary to years of rhetoric around ‘the sanctity of the family unit’ as a conservative principle, when they are saying that parents actually cannot make health care decisions for their families and that parents cannot decide what name their child will be called at school.”
Misinformation about gender-affirming careWhile traveling out-of-state for gender-affirming care is difficult, especially for young people, it’s not impossible. Teter said when he needed top surgery 10 years ago, there were no surgeons in Colorado who offered that care, so he flew to Florida for surgery and then flew back. But transgender children are not getting gender-affirming surgeries, he said.
“The care that young people are actually getting is behavioral health support, and so prohibiting young people’s ability to access that care is horrific, and that is the kind of thing that families are going to have to relocate for,” Teter said.
Pediatric gender-affirming care happens in a “wraparound” setting where care is ongoing, Teter said. Medical and behavioral health providers work together, and the patients are “highly supervised” more so than adult patients. Teter said he sees his primary care provider once a year to refill his prescription for testosterone, and “that’s it.”
Floyd said given their clinical and behavior health background as a social worker, it’s frustrating to see misinformation around gender-affirming care for minors and “this belief that affirming care means all you’re allowed to do is give a child hormones and say ‘here you go.’” They said behavioral health is often the first step for a young person exploring their gender identity before they see a provider who specializes in gender-affirming care.
“No behavioral health provider that is practicing ethically is definitively telling someone they’re trans or not — that is a journey for the client to go on, (the) behavior health provider is there for support,” Floyd said. “They’re often that first step for youth and families because it can be a great place to explore and to ask those questions and get support.”
Providers who specialize in gender-affirming care will then evaluate what stage of puberty the child is in and discuss all the appropriate options available to them, Floyd said. They said like most other medical interventions, parents need to give consent, too.
“Often the first step for youth is what we call ‘social transition’ — changing hair, clothes, maybe name, pronouns, with ongoing behavioral health support,” Floyd said. “Then as the youth continues to age, if there are appropriate medical interventions that align with what the youth feels appropriate and that the family feels appropriate, that would be the next step.”
Floyd said Denver Health, which offers gender-affirming care to minors, has a team of “health educators” who can help answer additional questions families and their children may not get to ask their actual doctor.
Fear for providersThe Skrmetti decision could also affect the broader health care systems in states that protect gender-affirming care in a way that’s similar to how the Dobbs decision did, Teter said.
“In the same way that when we saw an increase of thousands of patients coming to Colorado to access abortion care, that meant that primary care providers saw additional patients who needed birth control appointments, because some of those birth control appointments that they might have had at Planned Parenthood would then be filled by abortion patients from Texas. I think there will be impacts like that,” Teter said. “I think as we did after Dobbs, health systems will expand their capacity and they’ll adjust their staffing and their hours and figure out what they need to do to take care of all patients.”
Floyd said many gender-affirming care providers did not feel comfortable publicly testifying at the Capitol this year on legislation that could affect their work out of fear of backlash.
“These are providers who are passionate about this care, who have spent their careers specializing in this and building relationships with families and clients, and to have that threatened is really scary,” Floyd said.
Colorado does not have equitable access to pediatric gender-affirming care across the state, Floyd said, as providers are “very much concentrated in the Denver metro area” with only “a handful” offering care in rural parts of the state.
Denver Health and Children’s Hospital Colorado offer gender-affirming care to minors, but both providers temporarily stopped that care earlier this year after an order from President Donald Trump prohibited the federal government from funding gender-affirming care for anyone under 19 and threatened to pull other funding from any entity that offers such care.
That order was blocked by a judge and care for minors has resumed, but Republicans in Washington continue to target access to gender-affirming care — a provision that was removed from the Republicans’ policy megabill would have prevented Medicaid funding from going to providers who offer gender-affirming care. Floyd said providers like Denver Health, which is a safety net hospital that relies on federal funding, would not be able to continue offering care if such a requirement becomes law.
In a statement to Newsline, Denver Health spokesperson Dane Roper said “Colorado is a state that allows gender affirming care to youth. This ruling does not affect Denver Health’s ability or commitment to continuing to provide that care.”
Children’s Hospital Colorado declined to comment for this article.
Floyd said many gender-affirming care providers already have long wait lists for new patients — a trend they expect will continue — and some will outright decline to see out-of-state patients. They said for many providers, the thought of not being able to offer the care they specialize in “is like a moral injury,” because the individual providers are not choosing to stop offering gender-affirming care, it’s their employers’ legal teams.
“The legal process doesn’t get to decide or validate anyone’s identity,” Floyd said. “Trans folks have existed, will continue to exist, regardless of what the policy landscape looks like.”