People take part in the annual Pride Parade in San Juan, Puerto Rico, on June 5, 2022. Ricardo Arduengo/AFP/Getty
“People are scared out of their minds,” Dr. Miguel Vázquez Rivera tells me.
The psychologist and executive director of the True Self Foundation, an LGBTQ advocacy nonprofit in Puerto Rico, says that he has seen a rise in clinical “anxiety, depression, and suicidal ideation” in transgender people across the island after Puerto Rico’s total ban in July of hormone replacement therapy (HRT), puberty blockers, and gender-affirming surgery for transgender people 21 and younger.
The ban, Senate Bill 350, is among the harshest in any state or territory, criminalizing any provision of gender-affirming care to minors with penalties—up to 15 years in prison, revocation of medical licenses, and fines as high as $50,000—which advocates worry could apply to parents as well as medical providers.
Out of every US state or territory that previously treated gender dysphoria in trans youth, Puerto Rico’s unique age of majority makes its law the most severely punishing: medical autonomy is only conferred at age 21, as are most other adult rights other than purchasing alcohol and joining the military.
Rivera is bracing himself for the inevitable public health consequences that the ban will bring. Unlike bans in other jurisdictions, Puerto Rico’s went into effect immediately: Providers were not able to taper their patients off hormones and blockers, leading to both physiological and psychological effects. “It was cruel, vicious, and undignified,” he says.
That also incentivized, or necessitated, unsafe medical care. “They’re not going to stop their transitions,” Rivera says. “They’re going to receive it illegally in black markets on the streets,” risking disease through needle exchanges, inaccurate dosing, and inadequate management of hormone levels without medical support.
On top of the ban for trans youth, the legislature also passed a law that allows medical workers to refuse to treat people on religious grounds. The law protects residents against discrimination on the basis of sex, race, and sexual orientation—but not gender identity, leading to fears that it could be leveraged to target transgender and non-binary Puerto Ricans.
“Puerto Rico has very rural areas where there’s only one nurse working a shift, so if that’s the only nurse, then it’s a matter of life and death,” says Karina Claudio Betancourt, director of the community organizing group La Tejedora.
It has always been incredibly difficult for all trans people—but especially youth—to get prescriptions for any transition-related care in Puerto Rico, where its availability has been far more limited than in much of the US.
It took Betancourt a year, even as an adult, to get a prescription for testosterone; they also cite other barriers like lack of rural clinics and frequent Medicaid denials (Medicaid is the primary means of health care for more than a third of Puerto Rico’s residents). “It’s also about a lack of resources and lack of doctors that are capable of actually tending to this community,” Betancourt says.
Youth face even more hurdles: Until the ban took effect, despite being more populous than 18 states, Puerto Rico had only three physicians providing gender-affirming care for youth and one clinic for young adults ages 18 to 21. Rivera estimated that about 100 people under the age of 21 are prescribed either puberty blockers or hormone replacement therapy on the island.
Now, Rivera is fielding a stream of texts and calls from community members and former patients who are considering leaving the island.
At least one woman, Güarix Agosto, already has. Agosto, who is 20, started HRT illegally without a prescription in Puerto Rico in 2022. Despite being socially out as transgender, and in psychotherapy, since 2018, barriers in the medical system still made it impossible for her to get care within the law.
She was finally scheduled for a medical appointment for surgery in July—but it was cancelled abruptly when Senate Bill 350 was signed. Her partner, who was receiving testosterone legally through a clinic, also lost his prescription immediately after the ban went into effect.
Agosto described the passage of the bill as “a final blow.” Shortly after it entered law, she moved from Puerto Rico to New York City, where she now lives in a shelter for LGBTQ youth.
“I had to leave Puerto Rico because my life had become completely unsustainable,” Agosto said in an email. “It was about years of abandonment, institutional neglect, and being pushed to the margins at every level.” Nevertheless, she said, “I love my island deeply.”
While some Puerto Ricans are leaving, others are questioning how to return. Victoria and her trans son Liam (both pseudonyms) live in New England, but return to Puerto Rico often to visit family. They had planned for Liam to attend the University of Puerto Rico: “It’s a source of pride to study in that college,” says Victoria, but that plan feels impossible now.
“We believe in the self-determination of our bodies and in the self-determination of our people.”
And a deeper anger simmers, especially for the Puerto Rican diaspora. “How many trans Puerto Rican kids are not able to dream of returning to their fucking country?” Victoria asks.
Rivera increasingly spends his days on the phone with trans community members discussing the risks and benefits of moving to protective states in the US. He has started to prepare his nonprofit for new programming, including fundraising to send youth to countries without bans for care.
In many ways, Rivera says, the ban reeks of bad science, claiming to address supposed harms to youth who regret transitioning without citing research or evidence—perhaps because little supports its case.
Medical research consistently finds that the proportion of trans youth who receive transition-related medical care is a fraction of one percent; that such care is associated with improved mental health and reduced depression, anxiety, and suicidality; and that within that group, regret is rare. Studies also show that detransition—ceasing social or medical transition—is both rare and the product of complex, rather than uniformly negative, reasoning.
While there are no studies on outcomes for trans youth in Puerto Rico, Rivera says his experience mirrors those studies: “We didn’t have an issue of overprescribing. We didn’t have an issue of not being thorough with evaluations. We did not have an issue of people regretting [treatment].”
“We deserve to thrive at home, not just survive in exile.”
On the contrary, conservative standards meant that trans patients in Puerto Rico underwent extra assessments and therapy prior to receiving medical care. “We had higher restrictions,” Rivera said, than other jurisdictions serving trans youth.
The political motivation, Rivera says, comes down to “wanting to be on the side of the President of the United States.” He and others see the remarkably harsh anti-LGBTQ bills as an explicit capitulation to the Trump administration—Puerto Rico’s conservative, pro-Trump governor Jenniffer González Colón previously expressed support for the pro-LGBTQ federal Equality Act, and even sent back a first draft of SB 350 with amendments to protect access to puberty blockers and other care for youth already receiving them. But when lawmakers rejected the amendments, Colón signed the bill anyway.
Puerto Rico’s residents are locked out of presidential elections, and have no voting representation in Congress—but the political current in Washington, Rivera says, “affects us directly.”
For trans Puerto Ricans like Agosto and Betancourt, colonialism and transphobia are woven together. “To be Puerto Rican in a trans body is to constantly fight against colonial, religious, and state structures that try to define us, silence us, or erase us,” Agosto writes.
Betancourt, of La Tejedora Puerto, says that many trans and queer Puerto Ricans “support the self-determination of our island because we believe in the self-determination of our bodies and in the self-determination of our people.”
Agosto, now in New York, says that she fled the island “with almost nothing but hope and survival instincts.” There, even living in a shelter and fundraising for support, she is able to get real healthcare—and, beyond that, to have “the possibility of building a dignified life.”
“I’ve made more progress in NYC in a few months,” she says, “than in years back in Puerto Rico.”
But that isn’t stopping Agosto from working towards a future where she can return to Puerto Rico.
“We deserve to thrive at home, not just survive in exile,” she says, “Until that’s possible, I’ll keep organizing, speaking out, and dreaming of a Puerto Rico where trans youth no longer have to flee to feel human.”