Ten states in the past three months have passed laws prohibiting what is known as gender-affirming care for young people, in a rapid effort by Republican lawmakers across the country.
The laws ban or significantly limit the use of puberty blockers, cross-sex hormones and transition surgery for people under 18. Last week, Indiana and Idaho became the most recent states to pass bans.
Before this year, just three state legislatures had enacted full or partial bans. In addition to the 10 signed into law, bans have passed at least one chamber of seven more state legislatures on the path toward enactment this year.
Florida’s state medical boards also issued a rule last year prohibiting doctors from offering gender-affirming care to new patients under 18. Though not a law, the decree has the same effect of ending care.
Two more state legislatures, in Oklahoma and South Carolina, have successfully pushed major hospitals to stop providing gender-affirming care for minors by linking the care to the use of public funds.
And Missouri’s attorney general on Thursday announced a temporary order severely restricting gender-affirming care for both adults and minors by mandating strict requirements including evidence of three years of gender dysphoria documented by physicians. It is set to take effect on April 27.
These state-level actions are part of a broader wave of anti-trans legislation that has been proposed and passed across the United States. And hospitals have faced significant harassment for providing gender-affirming care in the last few years.
Republican state legislators have called gender-affirming care experimental and harmful, and say that children are not mature enough to make permanent decisions.
Major medical organizations in the U.S. support this care, however. And opponents of the bans say they infringe on the rights of young people, parents and doctors, and pose significant mental health risks to a vulnerable population.
The A.C.L.U. of Indiana filed a lawsuit on April 5 after the governor signed a ban on gender-affirming care into law; families have sued in Florida; and advocates in other states have signaled their intent to sue. Court injunctions have temporarily stopped bans that were passed in previous years in Alabama and Arkansas.
In some states, teenagers already on medication for gender dysphoria will be permitted to continue treatment indefinitely or taper off until a set cutoff date. In states that have passed bans without exceptions, minors taking puberty blockers or cross-sex hormones will have to travel to another state or stop treatment entirely.
All 10 bills passed so far this year permit hormonal therapy and genital surgery for reasons other than gender transition, such as surgery for children with ambiguous sex characteristics or puberty blockers for those experiencing early puberty.
There is continuing research in the United States and Europe about the risks and benefits of gender-affirming care for young people. But the American Academy of Pediatrics and the American Medical Association have urged states not to interfere with or limit care, pointing to evidence that suggests allowing adolescents to access this care can reduce depression and the risk of suicide. Minors also need parental consent in states where they can get hormone therapy.
Some doctors who have voiced concerns about how and when adolescents should receive gender-affirming care joined an open letter last month opposing the bans.
“There is consensus in the field, and amongst these signatories, that gender-affirming medical care is important and beneficial for many transgender youth,” the letter said.
The bills have moved through G.O.P.-dominated legislatures and been signed into law by Republican governors in nine states so far this legislative session. In Kentucky, Republicans overrode the Democratic governor’s veto.
“In signing this bill, I recognize our society plays a role in protecting minors from surgeries or treatments that can irreversibly damage their healthy bodies,” Gov. Brad Little wrote on signing Idaho’s ban last week.
Several of the bans include significant exceptions: Arizona’s ban, passed last year, prohibits only surgery, which is rare among transgender teenagers. Georgia’s law bans cross-sex hormones and operations but not puberty blockers. And West Virginia’s ban allows the care to continue if two providers agree that the treatment is necessary to “limit self-harm, or the possibility of self-harm.”
That amendment was proposed by the Republican State Senate majority leader, Tom Takubo, who in a floor speech last month referred to significant mental health benefits that gender-affirming medical care has for some teenagers with gender dysphoria.
Who is affected
There are about 53,000 transgender adolescents in the states where some or all gender-affirming care has been banned, out of some 300,000 nationwide, according to estimates from the Williams Institute.
Many of the major gender clinics across the Midwest and the South typically treat only one hundred or two hundred adolescents, and not all of them are getting hormone therapy. Estimates from Reuters suggest that a few thousand young transgender people nationwide are on puberty blockers and cross-sex hormones.
Providers expect the bans and closures will put pressure on states where gender-affirming care remains legal. The gender health program at Children’s Minnesota has a wait list of around a year, according to its director, Angela Goepferd. She fears the list will grow as patients from nearby states seek care.
“As it stands now, there’s a huge hole for access to care for transgender adolescents through the center part of the country and across the South,” she said. “Kids already driving hours for care within their own state are going to have to cross state lines.”
For families who can’t afford that much travel, “their kids just won’t have access to care,” she said.
When Alabama’s ban was first passed last spring, the University of Alabama at Birmingham prepared to send its patients to neighboring states. Then a court paused the part of the law that banned gender-affirming medication.
“Now some of the neighbors that we called last May are calling us, because their states are passing laws,” said Hussein Abdul-Latif, a pediatric endocrinologist with the university hospital system.
Future bans
Lawmakers in more than a dozen states are considering bans or restrictions on gender-affirming care. Many of those states, however, have at least one chamber held by Democrats or have a Democratic governor, severely limiting the bills’ prospects.
Kansas Republicans passed a ban on gender-affirming care, but the Democratic governor, Laura Kelly, is expected to veto it, and the bill’s support so far is short of a veto-proof majority. Wyoming Republicans’ attempts at passing similar legislation died in the Legislature this year.
Bans seem more realistic in several other G.O.P.-controlled states, especially Texas and Oklahoma, where legislation has passed at least one chamber of the Legislature. Last year, Texas declared that providing gender-affirming care was child abuse, though a court has partly blocked the state from investigating families. Adolescents in the state are still able to get some care, but it’s not clear how many providers have ceased to offer services.
In Nebraska, Democrats brought the legislative session to a standstill by filibustering the state’s proposed ban, but the legislation has made headway in recent days.
And bills banning care in Montana and North Dakota have been sent to those states’ Republican governors.
In South Carolina, the measure has clear support: More than half the State Senate co-sponsored one of the bans introduced. And in North Carolina, which has a Democratic governor, Roy Cooper, Republicans introduced a ban last week — on the same day that they gained a veto-proof majority.
