Nicole Levy had gone to the pharmacy to pick up her regular medicine when she suddenly found out it was blocked.
For ten years the 45-year-old transgender woman, who lives in Tampa, Florida, had been getting her hormone replacement therapy (HRT) from the same doctor without any problems. Then, in May 2023, her prescription was denied without explanation.
"I kind of went into a freefall of emotions for a good week, just trying to figure out what was happening," Levy tells The Independent . "Then, when I did get the [clinic’s] receptionist on the phone, she started to cry.
"In my moment of confusion, I felt like I had to ask her: ‘Are you okay?’ And she said, ‘no.’ She didn’t know how she was gonna get her hormones either."
Both Levy and her doctor’s receptionist, who was also trans, had been caught up in a sweeping surprise attack on trans healthcare for adults by Florida governor Ron DeSantis and the state’s Republican-dominated legislature.
As well as banning gender transition procedures for under-18s , the new law imposed onerous restrictions for adults – including a ban on non-physicians such as nurse practitioners issuing HRT prescriptions – that cut off many people’s treatment overnight and pushed some clinics to stop providing any care at all.
Last month a judge struck that law down as unconstitutional , and both minors and adults can get their meds again. But local activists and clinicians say the year that Republicans all but banned trans healthcare did lasting damage and drove many Sunshine State providers out of the business entirely.
"The fear is absolutely not gone," says Andre Clarke, a co-founder of the Florida non-profit TransNetwork and practice manager at Love the Golden Rule, an LGBT+-focused medical clinic in St Petersburg.
Florida is just one example of how Republicans across the country have begun cracking down on trans adults’ access to such treatments , using a wide range of tactics reminiscent of past campaigns to ban abortion, which have often targeted healthcare providers.
"I am quite sure that DeSantis knew that everything was going to be overturned. But it stoked the fear, it stoked the hatred,” said Clarke. “That is a win for them, and it is a continued loss for our community."
'People were so scared they just loaded up their car and left'
When Ron DeSantis signed Senate Bill 254 into law last May, the impact was immediate.
Pharmacies refused to fill even theoretically legal prescriptions, while their lawyers debated the exact contours of the new rules. Providers immediately stopped transition care while they tried to figure out how to comply. Clinics that were able to keep up treatment were inundated with new patients, often forcing them to pause sign-ups.
Trans healthcare is a relatively rare specialism, and is often provided by budget-constrained non-profits and community health centres. That means a lot of trans people get their medicine from nurse practitioners rather than directly from a physician.
The new law meant that nurse practitioners could be jailed for a year if they treated adults for gender dysphoria. It also banned transition care from being prescribed via telehealth. And it required physicians to file complex new informed consent paperwork that experts , and later a federal judge, deemed inaccurate and confusing.
“There simply aren’t enough physician providers for this care, so it has interrupted care for thousands and thousands," Spektrum Healthcare CEO Joseph Knoll told the industry news site Fierce Healthcare .
Knoll tried to hire more doctors, but doctors were leery. According to The Washington Post , one asked for a $100,000 relocation fee; others wanted to be paid at least $250,000 a year; one even said he couldn’t take the job unless he was paid under the table.
"We were legally advised to discontinue all trans care," says Clarke. The main reason, he says, was liability: the state Department of Heath had ruled that clinicians could be sued if their informed consent paperwork wasn’t perfectly in order.
Except, Clarke alleges, the finalized version of that specific documentation wasn’t released — just a draft version, making everyone nervous they weren’t filing things correctly.
"No one knew what the official rules were,” Clarke said. “They were always a temporary statement pending a secret committee conversation, in a location that didn’t provide parking, in a private building where they could [accuse] anyone that wanted to protest it of trespassing."
The Florida Board of Medicine did not respond to a request for comment.
The forms themselves were also full of unusual provisions, telling patients that the treatment is "purely speculative" and providing no information about any benefits. US district judge Robert L Hinkle would later slam them as "untrue and misleading", detailing risks for treatments the patients were not even getting and "plainly intended to dissuade patients from obtaining gender-affirming care" rather than ensuring that patients were fully informed.
Golden Rule’s lead doctor, a veteran HIV researcher named Bob Wallace, was willing to take on the legal risk, and continued to offer the treatments. Still, they were just one clinic in a state that was rapidly becoming ever more inhospitable to trans people.
"As a mental health counsellor, I definitely saw an increase in depression [and] an increase in suicidal ideation," says another TransNetwork co-founder, Tristan Byrnes. "I saw people scared enough to just pack up and move, whether they had a plan or not, because they didn’t trust that it wouldn’t get worse.
"It was especially parents of minors, but not just parents of minors,” Byrnes said. “Adults were so scared they just loaded up their car and off they drove, hoping that once they settled in they’d find a job. We lost some really good people and advocates in our area."
Levy, who is a drag performer under the name TeMonet , says she went into "extreme depression, isolation, withdrawal, confusion" when DeSantis’ law took effect. It took her back to the first time she ever tried to get HRT in 2004, when her doctor flatly refused to prescribe it and violated health privacy laws by telling her scare stories about three other trans women whose lives, in his view, had turned out wrong.
"My need for healthcare is not cosmetic; it is not for vanity," says Levy. "It is literally healthcare to be who I choose to be, to be happy, in my inner self."
Doctors and nurses remain in shortage
In June 2024, a federal court overturned Florida’s ban for under-18s and most of its curbs on adult care, saying they violated the equal protection clause of the Fourteenth Amendment.
"The statute and the rules were an exercise in politics, not good medicine," wrote Judge Hinkle in a scathing decision. "The great weight of medical authority supports these treatments... there is no evidence that this kind of care is routinely provided so badly that it should be banned outright."
Another court decision last June shot down a DeSantis-backed ban on Medicaid paying for trans healthcare , while a case challenging a similar coverage ban for state government employees is still under way .
"As of this date, transgender minors in the state of Florida can access gender-affirming medical care," Samantha Past, LGBT+ rights staff attorney for the ACLU of Florida, says.
"The state cannot take transgender children away from their parents, or investigate parents, for allowing their child to access gender-affirming medical care. And adults in Florida can receive their care from non-physicians."
But the state government is appealing Hinkle’s ruling, and that has created continuing uncertainty. "A lot of doctors are afraid that they’ll have to open up and then shut it all back down again," Byrne says.
Indeed, with a conservative supermajority on the Supreme Court – which recently granted Donald Trump broad immunity from criminal prosecution – Clarke from the St. Petersburg clinic believes there is every reason to be concerned.
Many trans-focused nurse practitioners have permanently switched jobs, says Clarke. "So many people have disappeared... they may still live in Florida, but they’re not working for a Florida clinic, and that’s a massive cut to the number of people that can receive the care."
As a consequence, Golden Rule has patients coming from all over Florida because they cannot find the same care, or the same standard of care, elsewhere.
All of which illustrates how anti-trans politicians can make life difficult for trans people even when the courts rule in support of trans rights, not just in Florida but nationwide. As Past points out, Florida was actually the first US state to impose restrictions on adult trans healthcare, and Republicans elsewhere have followed suit .
And since DeSantis has made rolling back trans rights a centerpiece of his political agenda, trans activists are braced for further turbulence.
"In Florida there are so many veiled and unveiled attacks on our community," says Levy. "The fight is not over."
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