When Angelique Cedeno, 42, decided to explore medically transitioning last May, she struggled to find a provider she trusted to guide her through the process. She met with physicians who told her they didn’t provide gender-affirming care, or asked her – unprompted – if she was suicidal.
Then she found Spektrum Health, a nurse practitioner-led clinic for the LGBTQ+ community based in Orlando, Florida. Cedeno liked that at Spektrum, all her primary care needs could be met in one place, including therapy, regular checkups and hormone prescriptions. Most importantly, she could walk into the clinic knowing that every person on staff was knowledgable about serving trans patients and proud to provide them with competent and respectful care.
As the months passed, her trust in Spektrum only grew, especially when it came to her relationship with Joseph Knoll, the nurse practitioner in charge of her care and the founder and president of the clinic. Staying at Spektrum was “the best decision that I could have made” for her health, Cedeno said.
That changed on 17 May. Overnight, Knoll and every other advanced practice registered nurse in the state were prohibited from prescribing hormones for the purpose of gender transition, though they can still prescribe them for other reasons. The ban is no small matter, given that 80% of Florida’s 94,900 estimated trans adults previously obtained hormones through a nurse practitioner, according to data provided by Spektrum.
When combined with the other adult provisions of SB 254, including a mandate that any first appointment with a physician be conducted in person, the law has made obtaining gender-affirming care onerous – and sometimes impossible.
Though Cedeno still has medication on hand, she has started taking a lower dose to stretch out her supply, and worries what will happen if she runs out completely.
“Once you start hormone treatments, you start seeing changes – you start seeing yourself for who you believed that you were supposed to be,” she said. “The number one fear that I have is to step out there and no longer be able to live my true identity.”
On Tuesday, four state and national civil rights groups, including Southern Legal Counsel, GLBTQ Legal Advocates & Defenders, the Human Rights Campaign and the National Center for Lesbian Rights, filed a motion asking the district judge Robert Hinkle to issue a preliminary injunction barring the state from enforcing the law. The judge previously issued a separate emergency injunction against SB 254 that only applied to the provisions affecting minors.
“Because nurse practitioners have risen to the occasion to serve communities that are otherwise discounted by other areas in healthcare, that created a unique opportunity for politicians to be hateful – to use us as a weapon,” Knoll said. “And that’s really scary to think about, because when does that stop?”
When SB 254 was first introduced in March, the fact that it would affect adults was scarcely mentioned.
“The bill protects children from being subjected to sex-reassignment prescriptions and procedures,” said the state senator Clay Yarborough in his press release.
It came as a surprise to many nurse practitioners and trans adults when they learned just how profoundly the bill would affect their lives.
“I was blown away,” said Brian Martinez, the senior operations director at the Hope & Help clinic in east Orlando, which serves many trans clients.
Some providers scrambled into action. Spektrum as well as Planned Parenthood of South, East and North Florida, which similarly relied on nurse practitioners to provide gender-affirming care, extended the prescriptions of as many patients as they could.
In addition to limiting who could prescribe hormones to trans people, SB 254 also directed the state’s boards of medicine and osteopathic medicine to develop regulations governing how gender-affirming care could be conducted – rules they had not yet written. For about seven weeks after the law went into effect, doctors could renew prescriptions but not write new ones.
Before 17 May, Spektrum averaged starting 10 new patients on hormones each week, said Knoll. Suddenly, those patients could not even turn to doctors unless they left the state. Gender-affirming surgeries were canceled or postponed, according to the lawsuit.
Meanwhile, the boards were holding regular public meetings about the rule-making process. Andrea Montanez, a prominent trans activist in the Orlando area and the LGBTQ Immigration Organizer at the Hope Community Center, attended every meeting, sometimes by getting in the driver’s seat of a passenger bus and picking other people up en route.
The meetings were emotionally charged and frustrating to attend, said Montanez. Attendees were sometimes given only 30 or 60 seconds to speak. When members of the far-right group Moms for Liberty got up to the microphone, they sometimes called trans people “groomers” and “devils”.
To Montanez and the other opponents of SB 254, it seemed clear that the boards’ members – most of whom were appointed by Governor Ron DeSantis – had already made up their minds. Last year, the Tampa Bay Times reported that board of medicine members donated at least $80,000 to DeSantis’s gubernatorial campaigns or political committee.
On 7 July, the boards finally issued the emergency rules. In order to obtain a prescription for hormones, trans adults are now required to sign and initial an extensive informed consent form, which inaccurately states that gender-affirming care is “based on very limited, poor-quality research”. The law specifies that these forms be signed with a doctor in person, meaning people who could previously attend visits via telehealth now must drive two or three hours. The forms “are horrible”, said Montanez – but will enable some people to begin or resume care.
Under the rules, those just beginning hormone treatment are also required to obtain a “thorough psychological and social evaluation” by a psychiatrist or psychologist, a mandate that is out of step with widely accepted standards of care put forth by the World Professional Organization for Transgender Health. For transgender patients, who are more likely to be uninsured and living in poverty, these various requirements can create logistical and financial obstacles to care that are insurmountable, said advocates.
The law has also placed substantial burdens on clinics, many of which have stopped taking on new trans patients – or reportedly stopped treating trans people altogether. Before May, Planned Parenthood of South, East and North Florida relied on 19 nurse practitioners to provide gender-affirming care to thousands of patients. In order to ensure continuity of care, all those individuals must now be seen in person by one of seven doctors. As a result, Planned Parenthood is not currently taking on new trans clients, though it hopes to do so down the line.
Providers that are able to take on new patients have seen a huge influx. In June, Hope & Help welcomed about 70 clients seeking to continue their gender-affirming care, up from an average of 10 in previous months, said Martinez.
With such a shortage of providers able and willing to provide care, many trans patients have struggled to book appointments. Soup, a 21-year-old who asked to be identified by their nickname since they are not yet out to their family, spent months on a waiting list to see a physician – at a clinic two and a half hours away. In early July, they made the drive and finally renewed their prescription for testosterone.
Had circumstances been different, said Soup, they might have had to use rent money to make the trip possible. Instead, they were able to cover their travel and appointment expenses with a $500 grant from a non-profit called the Campaign for Southern Equality.
The Campaign for Southern Equality’s Southern Trans Youth Emergency Project was launched in February 2023, with the aim of providing financial assistance to families affected by youth bans on gender-affirming care. After the scope of SB 254 became clear, the project was expanded to include adult Floridians. Since May, the organization has distributed at least $120,000 to this population.
“The premise of this work is that when the state intervenes to restrict or ban access to gender-affirming care, we will intervene to create bridges to care,” said its executive director, Jasmine Beach-Ferrara.
Local funds have also been launched to support trans people affected by SB 254, including the Central Florida Emergency Trans Care Fund.
Some other trans Floridians may be resorting to more desperate measures. Montanez said that since SB 254 came into force, she had heard of people attempting to obtain hormones illicitly, either because the process of securing a new prescription is so difficult, or because they are fearful the informed consent forms could be used to create a government registry. A portion of the trans community has always relied on the underground market to find medication, she said. “But now it’s worse.”
Lamia Moukaddam coordinates the syringe exchange program at Hope & Help and has been working to ensure trans people know about the service. “That way if people are going to self-transition, they can do it in the safest way possible.”
Even for patients who haven’t had their care interrupted, the reality of SB 254 has taken a profound psychological toll.
“I have received messages saying, ‘I don’t know how much longer I can do this,’” said Sam Cahen, a nurse practitioner and the transgender and non-binary care program director at Planned Parenthood of South, East and North Florida.
Knoll, the nurse practitioner who founded Spektrum, said he had one trans patient who decided to stop their hormone treatment altogether because “they would rather live inauthentically as a cisgender male” than with the stress caused living under Florida’s anti-trans laws.
“This is my speciality. I’ve spent so many years with so many thousands of people, helping them be themselves and happy and healthy,” said Knoll. “To hear that someone is essentially going back into the closet because of bureaucracy and politics? That’s devastating.”
Nor is SB 254 the only issue on the minds of trans Floridians. On 1 July, a new bathroom bill went into force, barring trans people on any publicly owned or leased property – such as university campuses, airports, or government-run buildings like libraries – from using the restroom that corresponds with their gender identity. Earlier this month, the board of education passed rules prohibiting teachers, even with the permission of parents, from referring to trans children with their correct name and pronoun. The crisis for trans people in Florida “transcends every area of life”, said Brandon Wolf, the press secretary for Equality Florida.
What’s happening in Florida is of particular importance as bans on gender-affirming care for youth proliferate across the country. Simone Chriss, a lawyer at the public interest firm Southern Legal Counsel, has played a primary role in challenging many anti-trans policies in the state. In Florida, they were “blindsided” by the attacks on adult gender-affirming care – yet now SB 254 is the law. “It’s the perfect example of what we’re seeing nationwide, which is that taking this care from children is just the first step. It’s an easier lift. It’s easier for people to swallow.”
Back at Spektrum, Angelique Cedeno can no longer receive her hormone prescription from Knoll. But he helps by keeping her and other patients up to date on the latest legal developments. When she retreats into herself, fearful to leave the house, he encourages her to volunteer at the clinic. When she worries about her continued access to hormones, he reaffirms that her womanhood is real and true regardless of medication.
