For one patient, the barriers to getting gender-affirming care manifested one facial hair at a time.

The patient, a mid-20-year-old who was assigned male at birth and began transitioning to female in their early twenties, had long been distressed by the physical changes of male puberty, particularly the development of facial hair. That’s why antiandrogen medications, like spironolactone, have been essential, said their doctor, an adolescent medicine specialist at a major academic medicine center in the mid-Atlantic, who — like other experts in this article — spoke under condition of anonymity out of concern for their personal safety.

Historically, that medication has been just one arrow in endocrinologists’ quiver for providing gender-affirming care. Puberty blockers — gonadotropin-releasing hormone (GnRH) analogues — are typically used in early puberty to pause pubertal progression. In contrast, antiandrogens are more often used later to suppress androgen effects once puberty has begun. Other gender-affirming hormones, like estrogens, are also frequently used after puberty to induce traits associated with patients’ identified sex, such as breast tissue.

However, a growing number of state-level laws — in addition to federal actions doubling down on previous restrictions — now limit or prohibit certain forms of gender-affirming care for minors. That’s led some hospital-based programs, including Children’s Hospital of Los Angeles, to pause services amid legal uncertainty. Or to suspend them entirely.

As gender-affirming care becomes harder to access, what happens to patients who need treatment and what can doctors do to help them without running afoul of state or federal rules?

Physical and Mental Health Consequences

The inability to get care affects patients in different ways depending on where they are in their transition.

If hormone blockers aren’t prescribed before puberty, the patient’s body will develop features of the nonidentified sex — the emergence of female breasts in someone identifying as male, for example, said a pediatric endocrinologist at a major academic medical center in the Southeast.

Interrupting hormone therapy also can have dramatic repercussions, especially for those in mid puberty. Those interruptions could mean the reemergence of features of the undesired gender within weeks or months — for example, the return of menstrual cycles, the growth of undesired body hair, or absence of fatty tissue development. In those situations, “it can feel like we’re losing whatever progress we gained,” the pediatric endocrinologist said.

In some cases, disruptions to care can be reversed in the long run, the physician said. Menstrual cycles can be halted when GnRH blockers like leuprolide are restarted, just as facial hair can recede when testosterone blockers like spironolactone are resumed. But if the disruptions last too long — through the end of puberty — other sex characteristics can be hard to reverse. Menstrual cycles may resume if puberty suppression is interrupted; likewise, androgen-driven hair growth can reemerge. And while some effects may be partially mitigated if treatment is resumed, others — such as voice deepening or breast development beyond certain stages — are largely irreversible without surgical intervention, the pediatric endocrinologist said.

As features of sexual development such as facial hair or menstrual cycles return or progress in the absence of hormone therapy, “patients think, ‘I am not the version of myself that I want to be,’” the adolescent medicine specialist from the mid-Atlantic said.

That narrative can set off a cascade of negativity. The onset of puberty in transgender children leads them “to feel like their body is changing in ways they can’t control,” said a pediatrician at a major healthcare system based in northern California who cares for children with gender dysphoria.

In those situations, “we see a lot of depression, a lot of self-harm, a lot of eating disorders. Kids will try to change how their body is changing by starving it or overeating or using weight as a way to look more or less masculine,” the pediatrician added. “There can be a lot of self-hatred that comes out during that time.”

Research shows that the onset of puberty associated with patients’ biological sex — and the absence of sexual features associated with their identified gender — has significant mental health consequences. One study on the impact of 48 new anti-transgender laws across nine states between 2018 and 2022 found that their implementation was associated with an increase in suicide attempts among youth. Other studies have found significant risks associated with interrupted transitions and detransitioning. While these studies demonstrate strong associations between restrictive policies and adverse mental health outcomes, they do not establish direct causality, and authors have noted the influence of confounding factors such as baseline mental health conditions and social stressors.

Conversely, studies have found that gender-affirming care can make a significant difference in patients’ mental health. A study in JAMA Network Open found that, for patients with gender dysphoria at federally qualified health centers in New York and Boston, receipt of hormone therapy reduced the risk for moderate or severe depression by 15%.

These findings “contribute to the evidence base that [hormone therapy] is a medically necessary treatment that improves mental health outcomes longitudinally for transgender, nonbinary, and gender diverse people,” the authors wrote.

How to Support Patients

Amid the evolving national and regional restrictions, patients and clinicians still have some options.

After the 2023 passage of House Bill 808 in North Carolina, which prohibits gender transition procedures for minors, doctors in the state quickly learned elements of care, including physical therapy, counseling, and pastoral care, remained viable options for their patients, according to reporting in Harvard Public Health.

Options like voice therapy and prosthetic devices to support an appearance in line with the patient’s identified gender may also exist in regions where hormone therapy is banned, the pediatric endocrinologist from the Southeast said. “We can do things that help them align with their preferred gender even if they’re not taking hormones,” the physician added.

In some cases, patients may be able to cross state lines to acquire medications — the administration of which could be overseen at their home clinic. Additionally, some telehealth services such as Plume Clinic appear to still offer mail-order options for hormonal medications. Plume Clinic did not respond to multiple requests for comment. Experts cautioned that clinicians should remain mindful of their own state’s legal framework when discussing out-of-state or telehealth options and may wish to consult legal counsel before providing guidance.

In cases where patients can no longer access hormone-based or other medical treatments, it’s essential for clinicians to offer mental health support to help patients deal with the significant risks associated with interrupted transitions, experts said.

One option is “gender expression care,” which provides “everything up to but not including hormonal care,” said the adolescent medicine specialist from the Mid-Atlantic. A 2023 article in NEJM Catalyst describes gender expression care offered through Kaiser Permanente as an “immediate and noninvasive treatment approach to gender incongruence” that includes a multimodal approach of mental health and social supports beyond medical care alone.

The organization continues to offer this care in Northern California, with plans to expand access to it in 2026. “Kaiser Permanente is dedicated to providing safe, high-quality, and evidence-based care to all our members, including adolescents,” a spokesperson wrote in a statement. “We will remain a voice and advocate for safe, high-quality, and evidence-based transgender care.”

Physicians also can make sure information about hotlines is available in their offices. Although the federal government in June cutoff funding for the LGBTQ-specific line (colloquially called the “Press 3 Option”) on the 988 suicide prevention hotline, those seeking help can still call the general 988 number. Several advocacy organizations, such as The Trevor Project, also operate hotlines.

In some cases, social media may play a supportive role.

“I do think that online communities — for better or for worse — there’s a huge amount of support that kids find in them,” the northern California pediatrician said. “For a lot of my patients who live in unsupportive environments, those communities become a lifeline.” Research looking at social media use by transgender people specifically has highlighted potential benefits, such as through the identification of inclusive safe spaces, that may provide an outsize impact for socially isolated children. Other studies, though, caution the use of these platforms in transgender youth due to disproportionate risks for online discrimination and bullying — among other concerns — compared with the broader population.

If nothing else, there are the day-to-day things clinicians can do to offer patients support, experts said. They could wear ally pins or place an ally flag in the office. They can ask patients their preferred names and pronouns.

These are “really powerful small things that people can do,” the California pediatrician said. “These kids are taking notice of people standing up for them.”

Eli Cahan is an investigative journalist whose work frequently appears in Rolling Stone, ProPublica, JAMA, and elsewhere. He is also a neonatal intensive care physician based in California.