As Florida restricts treatment for trans adults, one clinic presses on

ORLANDO, Fla. - Any day now, Joey Knoll told himself, he’d grab the bullhorn he kept at the edge of his desk, and he’d tell everyone at Spektrum Health that their year-long nightmare was over.

All of Knoll’s patients had been on edge since the Florida legislature banned nurse practitioners like him from prescribing hormones to trans people. Florida doesn’t have nearly enough doctors to take up the slack, and so, for many patients, the care simply disappeared when the law took effect last May. A judge had the power to change that.

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Knoll booted up his computer, and he listened as Lizzo’s “2 B Loved (Am I Ready)” played in the hallways. Spektrum had always been a fun clinic. People brought their pets to work, and Knoll, a 39-year-old gay man, sports a dyed blonde mohawk. But the pop song echoed down empty hallways now, and Knoll knew his inbox would once again be filled with messages from desperate patients.

Nearly 150 were out of medicine, and others were nearing the end of their supply. Even Spektrum’s chief operating officer, a trans woman, had just one refill left.

Without hormones, many had become depressed and anxious. Trans women were growing body and facial hair. Trans men said their periods had returned after a few missed doses. The state had turned on them, they said. Now, their bodies were turning on them, too.

Knoll had nowhere to send them. Every doctor he knew had a full practice, and others told him the political climate had become too dangerous to treat trans people. The legislative ban laid out all sorts of regulations not grounded in science, and if health-care providers missed one, they could spend time in prison.

Knoll hadn’t felt exactly shocked when the law passed. Over the last three years, Republican-led legislatures had introduced a record number of bills that whittled away LGBTQ rights. Politicians had targeted schools and sports teams, bathrooms and bars, and two dozen states had passed sweeping laws that prohibited adolescents from transitioning. But no state had gone as far as Florida.

Knoll glanced at the bullhorn. He’d told himself every morning since late December that today was the day he’d use it. A group of patients had argued that the law discriminates against trans people, and they’d sued the state to overturn it. The judge had said just before Christmas that he would rule soon. Months had gone by, though, and Knoll and his patients were still waiting.

Knoll loaded the court website and imagined what he’d do if the judge overturned the ban. He would rush into the clinic’s rainbow-colored hallways, and he’d use the bullhorn to tell his staff it was time. The state would appeal, so they’d have to act fast. They’d call the patients who were out of medicine, then Knoll would write as many prescriptions as he could.

Lana Dunn, Spektrum’s chief operating officer, peeked in as the court docket loaded. Knoll sighed. The last update was still a post-trial brief the state had filed in January.

“There are common and respectable reasons for regulating gender-dysphoria treatments,” lawyers for the state had written. “Believing that better medical standards should be in place for a relatively new medical condition doesn’t amount to intentional discrimination.”

Knoll didn’t understand why state officials thought nurse practitioners weren’t already surpassing medical standards. No one had ever analyzed his patient outcomes, and several researchers have found that patients fare just as well when they see a nurse practitioner.

“If it’s a no, what are we going to do?” Dunn asked.

Knoll adjusted the stethoscope he’d draped across the collar of his neon pink button-down. Some of his patients had turned to the black market. Others were despondent. He didn’t want to imagine what they’d do if the ban remained.

“I can’t tell you,” he said. “I don’t have answers for that.”

- - -

When Knoll moved to Florida in the early 2000s, he found it as welcoming as the New York neighborhood he’d left behind. He had gay friends, but he made straight ones, too, and when he began his nursing career, he didn’t look for LGBTQ-specific clinics. Knoll knew queer people suffered, but he felt others did, too, so he took jobs in hospitals and nursing homes.

That changed in 2016 when a gunman killed 49 people and wounded 53 others at Pulse nightclub, a gay bar in Orlando. The shooting was the country’s deadliest act of violence against LGBTQ people. It reshaped the way Knoll thought of himself. He no longer wanted to live or work as if being gay were just an incidental fact of his life. The next year, he took a contract job at an LGBTQ clinic treating trans patients.

The work felt so rewarding, Knoll spent much of his free time trying to become better at it. He read books about treating LGBTQ patients. He found mentors who’d offered the care for decades, and he went to conferences to learn about the risks queer people face in medicine.

Florida has more than 111,000 trans people, but appointments for hormones were still relatively hard to come by in 2017. When Knoll’s contract work ended, he opened Spektrum as a nonprofit offering primary and gender-affirming care.

Though Florida was turning increasingly Republican, the state still felt queer friendly. After the Pulse shooting, all of Orlando seemed to hoist rainbow flags, and when Ron DeSantis became governor in 2019, he visited a memorial for the shooting and said his administration would not tolerate hate against the LGBTQ community.

Trans people felt so safe coming out here, Knoll’s practice added at least 10 new patients every week. He brought on therapists and three nurse practitioners, then he opened a second location in Brevard County, one of Florida’s more conservative areas. By 2022, Spektrum had nearly 5,000 patients, a mix of adults and adolescents.

That sense of safety seemed to vanish overnight. As trans people ran for office and starred in television shows, right-wing strategists decided they could be used as a wedge issue to drive conservative voters to the polls. Groups such as the Heritage Project and Alliance Defending Freedom wrote model legislation to curb trans rights, and in 2022, states introduced a record number of anti-LGBTQ+ bills.

In Florida, DeSantis signed what critics call the “don’t say gay” bill, forbidding instruction on gender identity in the classroom. His administration targeted drag clubs and directed the state’s medical board to prohibit minors from transitioning. Then, four days before the 2023 session opened, Florida became the first in the nation to introduce health-care restrictions for transgender adults.

All of a sudden, Knoll knew he wouldn’t just need to treat patients. He’d have to fight for their rights, too.

- - -

Knoll stayed up late all spring, watching hours-long legislative hearings from his backyard after a full day of seeing patients. Republican state lawmakers had proposed 10 anti-LGBTQ+ bills, including two that banned nurse practitioners from prescribing hormones to trans patients.

Nearly two dozen states had moved to ban young people from transitioning, but no other legislature wanted to limit adults’ access to care. In Florida, Democrats pushed the Republican sponsors to explain why they hoped to be the first.

“What is the state’s compelling interest to interfere with adults’ freedom to make the sort of informed decisions for themselves?” Rep. Robin Bartleman asked Rep. Randy Fine in a March 2023 committee meeting after he introduced the House version of the ban.

“We’re not limiting their access to health care,” Fine said. “We’re making sure that they have health care in a safe fashion.”

Knoll does not consider himself an emotional person. He tends to be even-keeled and sunny, but he felt full of rage watching the hearings. Fine wasn’t just critical of protecting trans rights, he was dismissive of their very identity. Online, he referred to trans people with quotation marks. He described transgender health care as “fraud” and “evil.” And when he wrote about the bill, Fine said he planned to “relish the battle ahead.”

Fine later told The Washington Post he doesn’t think being transgender is “real,” but he dismissed the idea that his bill prevented adults from transitioning. Doctors could still prescribe hormones, he noted.

Fine represents Brevard County, the coastal community where Spektrum opened its second location. Fine has never visited Spektrum or any other gender clinic, but he said Brevard is a big county with more than 600,000 residents and plenty of doctors.

“If you can’t find a doctor here to prescribe something this serious, then maybe there’s a much larger discussion that people should be having,” Fine said.

Fine described nurse practitioners as “less educated” than doctors, but nurse practitioners can assess patients and prescribe medications, and clinics across the country use them to provide primary care. In Florida, they fill a critical gap: The state is expected to have a shortfall of 18,000 doctors by 2025.

Knoll knew many of his patients would lose access to hormones if he couldn’t prescribe them, and he worried they’d suffer. Hormones regulate a person’s mind and body, and going cold turkey could send patients into depressive spirals or worse. Patients without ovaries or testes no longer produce hormones. Without them, they’d be at an increased risk of osteoporosis and heart disease.

Knoll and his staff worked extra hours to ensure most patients would have hormones through the summer, but by the time the bill reached the governor, hundreds still hadn’t scheduled an appointment.

DeSantis signed the bill in mid-May at a private Christian school in Tampa. A local website live-streamed the event, and after Knoll saw his last patient of the day, Spektrum’s staff crowded around Knoll’s desk to watch the governor’s news conference.

“We have a very crazy age that we live in,” DeSantis told the children who’d gathered to watch him sign the legislation. “There’s a lot of nonsense that gets floated around, and what we’ve said in Florida is, we are going to remain a refuge of sanity and a citadel of normalcy.”

Seven of Knoll’s nine employees are transgender, and as DeSantis signed the legislation, Knoll fought back tears. His job had just fundamentally changed, but his employees and patients had lost something bigger. All session, Republicans lawmakers had talked about trans people as if they were dangerous. Now, the governor had taken away the medication that made them feel like themselves.

Knoll and his staff watched as the governor threw his bill-signing pens into the audience like a musician tossing guitar picks at the end of a show, then the feed went dead.

When the last employee left for the day, Knoll shut his door, sat at his desk, and cried.

That spring, Spektrum started selling “Don’t Tread on Me” T-shirts with a rattlesnake coiled against a trans flag. American Revolutionaries first used the symbol in the 1700s, and though it has been co-opted by anti-government members of the tea party, Knoll sold it as a way of reminding people that American liberties were at stake.

The law went against the training Knoll learned in eight years of nursing school programs, but nurse practitioners could go to prison for a year if they treated adults for gender dysphoria and up to five if they offered the care to minors, so he decided to comply. He tried to hire a doctor so Spektrum could continue offering hormone therapy. He placed ads and made calls, but the new law made most doctors too nervous to commit.

One demanded a $100,000 relocation fee, Knoll said, and the others told him they needed to earn at least $250,000 a year - a stretch for a nonprofit that barely breaks even. Another said he’d take the job only if he could be paid under the table.

By late summer, Knoll realized all he could do was wait for a judge to intervene.

- - -

Over the last three years, as nearly half of U.S. states have moved to restrict transgender health care, patients have turned to the court system for help. Parents with trans children filed suit in Arkansas, Indiana and Tennessee, and a group of anonymous families sued Florida over its restrictions, too. That July, one of Knoll’s adult patients joined their case.

When the trial began in December, Lucien Hamel testified that as soon as he’d learned the difference between boys and girls, he’d known he wasn’t a girl. He didn’t have a word for the feeling back then, but he felt anxious and distressed when he was grouped with girls or thought of as one.

After Hamel gave birth to his son in 2016, his depression and “feeling of incongruence” intensified. He struggled to connect with his son. He thought he had postpartum depression, so he found a therapist, but he realized in those sessions that what he actually had was gender dysphoria. (Hamel’s lawyers declined to make him available for an interview with The Post.)

A pediatric endocrinologist eventually prescribed him testosterone. The medication changed Hamel’s body and his life.

“I started to look more and more like an authentic version of myself,” he testified. “I had a much better relationship with my child after that point.”

Eventually, the pediatric endocrinologist told Hamel his practice no longer wanted him to treat adults. The doctor referred Hamel to Spektrum. There, Hamel told the judge, he received care that was “pretty much letter for letter” what he’d received at the endocrinologist’s office. If anything, Spektrum’s nurse practitioners seemed more careful. They had Hamel come in for labs every three months, rather than every six.

When DeSantis signed Senate Bill 254, Hamel said he felt “incredibly lost.” He didn’t get in for an appointment before the bill passed, and by the time his next one came up in June, he was too late. No one at Knoll’s clinic could prescribe hormones.

Hamel searched for a new provider, but most were booked through 2024. The only clinic with open appointments was three hours away in Miami, and it charged a $385 nonrefundable fee on top of all medical costs.

Hamel ran out of testosterone before he could find a doctor. Without it, he testified, he’d lost “significant muscle mass,” and his hips had “widened in a very feminine way.”

“I’m afraid people will start to see me as a woman again,” Hamel told the judge. “I’ve come so far in establishing myself as Lucien, as the man that I’ve always known myself to be, and for that to be taken away from me by a law under the guise of, you know, making sure that I receive the best care or whatever, it’s scary.”

Knoll felt optimistic. The judge, a Bill Clinton nominee named Robert L. Hinkle, legalized same-sex marriage in Florida before the Supreme Court did. In an earlier, temporary ruling against the ban on adolescents, Hinkle had called the bill “an exercise in politics, not good medicine.”

When the trial ended four days before Christmas, the judge thanked everyone for their professionalism, then said he would try to deliver an opinion “as quickly as I can.”

- - -

Winter passed without a verdict. Mid-February, Spektrum’s board of directors decided to close the organization’s location in Brevard County. That clinic’s lone nurse practitioner had quit the previous year, and Knoll had yet to find anyone willing to take her place.

In some ways, shutting down the Brevard County office hurt more than watching DeSantis sign the bill. The clinic’s rainbow flag was the only one in town, and Knoll knew it had been more than a place to get health care. In court, Hamel testified that he’d felt isolated in his community as a trans person before he visited the Brevard County clinic.

“I went to Spektrum, and there are nurses there that I saw were trans,” Hamel testified. “It was the first time really I had met, like, another trans person who lived in Florida.”

The Orlando location was quieter than it had been before the ban, but Knoll intended to keep it open for primary care. Trans people came down with colds and infections, the same as anyone else, and they wanted a provider who understood them.

His first patient on a recent morning had pinkeye, and the second was a trans woman who’d found a doctor in Georgia who was willing to prescribe estrogen as long as someone in Florida monitored her hormone levels.

Knoll bounced into the room wearing a blue button-down with a pattern as busy as a Magic Eye poster.

“Hi! How are you?” Knoll asked the woman, a 33-year-old named Key-Rei Kestrel. “Have you seen your labs? They’re perfect.”

Knoll loaded Kestrel’s records, then tilted his computer so she could see. Her liver, kidneys and electrolytes all looked good. Her testosterone levels were low, and her estrogen was well within the target range.

“I wanted to thank you,” Kestrel said. “You saved my life. But at the same time, you didn’t save my life. You gave me life.”

Kestrel pulled out her old driver’s license and handed it to Knoll. She was 100 pounds heavier in the picture and angry. Back then, she told Knoll, she didn’t have any friends.

“I don’t even know who this person is,” she said.

Kestrel told Knoll she knew she was lucky. Most of her friends couldn’t afford to travel for care, and she could. Still, it didn’t seem right. Why should she have to spend 12 hours on the road, wearing down her car, wasting her vacation days, to get health care in Georgia that Knoll was qualified to give her close to home?

That wasn’t the only thing that had changed since the law had passed. She felt a new sense of hostility that scared her. A man at her work had said he hoped DeSantis legalized “transgender murder squads,” so he could shoot her and leave her to rot in a ditch.

Knoll tried to reassure Kestrel. All his patients had a story, and he did, too.

“Do you want a hug?” Knoll asked.

“I kind of do,” Kestrel said.

After the appointment, Knoll headed to the conference room. It was Dunn’s birthday. Someone had set up a store-bought red velvet cake with candles, and as the group sang “Happy Birthday,” Knoll looked around. Every day, his employees grappled with how to care for patients the law restricted them from treating. He worried it all amounted to a front-row seat to trauma. Sometimes, he considered closing the clinic entirely.

Dunn closed her eyes, then blew out the candles. The clinic’s other nurse practitioner told Dunn she hoped all her wishes came true.

“Just the one,” Dunn said. “Come on, Judge Hinkel.”

“Oh, let me go check,” Knoll said. “Oh my God. This would be a really nice birthday gift.”

Knoll ran down the hall, suddenly sure this would be the day. He slid into his office chair, reached for the bullhorn, then hit refresh. Dunn walked in, holding a piece of uneaten cake. He knew she’d called doctors around the state, and he knew she couldn’t get an appointment anywhere.

“Nothing?” Dunn asked.

Knoll looked up, and the optimistic smile he tried to maintain faded. He was a nurse. He was supposed to help people. Dunn was his best friend, and he knew she’d be out of estrogen within a matter of weeks.

“Nothing yet,” Knoll said. “But I’m going to keep checking.”


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Video: In July 2023, the Florida legislature banned nurse practitioners from prescribing hormones to trans people. Now, one nurse-led clinic in the state anxiously awaits the outcome to a challenge to that law.(c) 2024 , The Washington Post

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