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FACT SHEET: Biden- ⁠ Harris Administration Advances Equality and Visibility for Transgender Americans

Today, the Biden-Harris Administration recognizes Transgender Day of Visibility, an annual celebration of the resilience, achievements, and joy of transgender people in the United States and around the world. Every American deserves the freedom to be themselves. But far too many transgender Americans still face systemic barriers, discrimination, and acts of violence. Today, the Administration once again condemns the proliferation of dangerous anti-transgender legislative attacks that have been introduced and passed in state legislatures around the country. The evidence is clear that these types of bills stigmatize and worsen the well-being and mental health of transgender kids, and they put loving and supportive families across the country at risk of discrimination and harassment. As the President has said, these bills are government overreach at its worst, they are un-American, and they must stop. Transgender people are some of the bravest people in our nation. But nobody should have to be brave just to be themselves. Today, the Biden Administration announced new actions to support the mental health of transgender children, remove barriers that transgender people face accessing critical government services, and improve the visibility of transgender people in our nation’s data.

Reinforcing federal protections for transgender kids. The Justice Department announced today that it has issued a letter to all state attorneys general reminding them of federal constitutional and statutory provisions that protect transgender youth against discrimination, including when those youth seek gender-affirming care. Advancing dignity, respect, and self-determination for transgender people by improving the traveler experience. For far too long, transgender, non-binary, and gender non-conforming Americans have faced significant barriers to travelling safely and many have not had their gender identity respected as they travel within the United States and around the world. To create a safer and more dignified travel experience, the Biden Administration is announcing the following changes.

• The Department of State is announcing that beginning on April 11, 2022, all U.S. citizens will be able select an “X” as their gender marker on their U.S. passport application. This is a major step in delivering on the President’s commitment to expand access to accurate identification documents for transgender and non-binary Americans. Information on how to apply will be available at travel.state.gov/gender .
• Implementing enhanced screening technology. The Transportation Security Administration (TSA) will soon begin updating its Advanced Imaging Technology (AIT) body scanners with new technology that will increase security and efficiency by reducing false alarm rates and pat-downs for the traveling public. By replacing the current, gender-based system with this more accurate technology, TSA will improve the customer experience of transgender travelers who have previously been required to undergo additional screening due to alarms in sensitive areas.  This new technology will help to improve the experience of travelers, particularly those who are transgender and non-binary travelers. TSA will begin deploying this new technology in airports throughout the country later this year.
• Expanding airline partnerships to enhance the overall travel experience.  TSA is working closely with air carriers across the nation to promote the use and acceptance of the “X” gender marker to ensure more efficient and accurate passenger processing. As of March 31st, two major domestic air carriers already offer a third gender marker option in their travel-reservation systems, with a third air carrier planning to offer this option in the Fall of 2022.
• Streamlining identity validation. TSA has updated its Standard Operating Procedures to remove gender considerations when validating a traveler’s identification at airport security checkpoints. This ensures that TSOs can accurately and efficiently validate each traveler’s identity while avoiding unnecessary delays.
• Updating TSA PreCheck and CBP Trusted Traveler Programs enrollment to include “X” gender markers. The Department of Homeland Security is beginning the process of adding “X” gender markers options in Trusted Traveler programs and the TSA PreCheck program to enhance access for transgender, non-binary, and gender non-conforming travelers to these programs.

Providing resources for transgender kids and their families. Transgender children are put at higher risk of attempted suicide or mental health challenges when they face bullying, rejection, or denial of health care. The Biden Administration is releasing several new resources to help transgender children and their parents thrive:

• Providing mental health resources for transgender youth.  In recent months, multiple states have removed critical information about mental health resources for LGBTQI+ youth from official state websites. Transgender youth often face significant barriers in accessing supportive resources, and are at greater risk of attempted suicide. In response, the Department of Health and Human Services released a new website that offers resources for transgender and LGBTQI+ youth, their parents, and providers. These resources include best practices for affirming an LGBTQI+ child, and information about suicide prevention services.
• Expanding trainings to support transgender and nonbinary students in schools. The Office of Safe and Supportive Schools in the Department of Education will offer new training for schools with experts and school leaders who will discuss the challenges faced by many transgender and nonbinary students and strategies and actions for providing support.
• Confirming the positive impact of gender affirming care on youth mental health. The Substance Abuse and Mental Health Services Administration (SAMHSA) has posted LGBTQI+ Youth – Like All Americans, They Deserve Evidence-Based Care , in which Miriam Delphin-Rittmon, Ph.D., HHS Assistant Secretary for Mental Health and Substance Use and the leader of SAMHSA, shares how to engage LGBTQI+ youth, the evidence behind the positive effects of gender affirming care, and available resources for LGBTQI+ youth, their families, providers, community organizations, and government agencies.
• Confirming that gender-affirming care is trauma-informed care. The National Child Traumatic Stress Network (NCTSN), which is administered by the Substance Abuse and Mental Health Services Administration, is releasing new information for providers confirming that providing gender-affirming care is neither child maltreatment nor malpractice.
• Providing resources on the importance of gender affirming care for children and adolescents. The Office of the Assistant Secretary for Health has developed a resource to inform parents and guardians, educators, and other persons supporting children and adolescents with information on what is gender-affirming care and why it is important to transgender, nonbinary, and other gender expansive young people’s well-being.

Improving access to federal services and benefits for transgender Americans.  With support and coordination from the U.S. Digital Service, federal agencies are removing barriers to access government services by improving the customer experience of transgender, non-binary, and gender non-conforming Americans:

• Accessing retirement savings. The Social Security Administration is announcing that it is removing the requirement that transgender people show proof of identity such as doctor’s notes in order to update their gender information in their social security record by the fall of 2022. This will significantly improve transgender individuals’ experience in accessing their retirement benefits, obtaining health care, and applying for jobs.
• Filing an employment discrimination complaint . The U.S. Equal Employment Opportunity Commission (EEOC) is announcing that it will promote greater equity and inclusion for members of the transgender community by giving individuals the option to select an “X” gender marker during the voluntary self-identification questions that are part of the intake process for filing a charge of discrimination.
• Applying for federal student aid. The Department of Education plans to propose next month that the 2023-24 FAFSA (Free Application for Federal Student Aid) will include an opportunity for applicants to indicate their gender identity as well as their race/ethnicity when applying for federal financial aid. The questions, which will be posted for public comment, will be in a survey that accompanies the application. This privacy-protected information would help to inform the Department about possible barriers students, including transgender and nonbinary students, face in the financial aid process.
• Visiting the White House.  The White House Office of Management and Administration is announcing that it is beginning the process of implementing updates that will improve the White House campus entry process for transgender, gender non-conforming, and non-binary visitors by adding an “X” gender marker option to the White House Worker and Visitor Entry System (WAVES) system. This change will ensure that transgender, non-binary, and gender nonconforming people can visit the People’s House in a manner that respects and affirms their gender identity.

Advancing inclusion and visibility in federal data. In too many critical federal surveys and data systems, transgender, non-binary, and gender non-conforming people are not fully reflected. To improve visibility for transgender Americans, agencies are announcing new actions to expand the collection and use of sexual orientation and gender identity (SOGI) data.

• The White House announced that the President’s proposed Fiscal Year 23 budget includes $10 million in funding for additional critical research on how to best add questions about sexual orientation and gender identity to the Census Bureau’s American Community Survey, one of our nation’s largest and most important surveys of American households. This data collection will help the federal government better serve the LGBTQI+ community by providing valuable information on their jobs, educational attainment, home ownership, and more.
• The Department of Health and Human Services has released the findings of the federal government’s first-ever user research testing conducted with transgender Americans on how they want to see themselves reflected on Federal IDs. This groundbreaking user research by the Collaborating Center for Question Design and Evaluation Research (CCQDER) at the National Center for Health Statistics (NCHS) directly informed the State Department’s adopted definition of the “X” gender marker.
• The Department of Health and Human Services  has released a comprehensive new consensus study on Measuring Sex, Gender Identity, and Sexual Orientation. This work, commissioned by the National Institutes of Health and carried out by the National Academies of Sciences, Engineering, and Medicine, will inform additional data collections and future research in how to best serve LGBTQI+ Americans.

These announcements build on the Biden-Harris Administration’s historic work to advance equality for transgender Americans since taking office, including: Combatting legislative attacks on transgender kids at the state level.

• Condemning anti-transgender bills. The President has consistently made clear that legislative attacks against transgender youth are un-American, and are bullying disguised as legislation. In his March, 2022 State of the Union Address, the President said, “The onslaught of state laws targeting transgender Americans and their families is wrong. As I said last year, especially to our younger transgender Americans, I will always have your back as your President, so you can be yourself and reach your God-given potential.” The White House has also hosted listening sessions with transgender youth and advocates in states across the country that are impacted by anti-transgender legislative attacks.
• Reaffirming that transgender children have the right to access gender-affirming health care. In March, following state actions that aim to target parents and doctors who provide gender-affirming care to transgender children with child abuse investigations, the Department of Health and Human Services took multiple actions to support transgender children in receiving the care they need and promised to use every tool available to protect LGTBQI+ children and support their families.
• Department of Justice statements of interest and amicus briefs. The Department of Justice’s Civil Rights Division has filed Statements of Interest and amicus briefs in several matters to protect the constitutional rights of transgender individuals, including in Brandt v. Rutledge , a lawsuit challenging legislation restricting access to gender-affirming care for transgender youth; B.P.J. v. West Virginia State Board of Education , a lawsuit challenging legislation restricting participation of transgender students in school sports; Corbitt v. Taylor , a lawsuit challenging legislation restricting the ability to change gender markers on state driver’s licenses; and Adams v. School Board of St. John’s County , which involves the right of a transgender boy to use the boys’ restroom at his school.

Advancing civil rights protections for transgender Americans

• Fighting for passage of the Equality Act.  President Biden  continues to call  on the Senate to pass the Equality Act, legislation which will provide long overdue federal civil rights protections to transgender and LGBTQI+ Americans and their families. As the White House has  said , passing the Equality Act is key to addressing the epidemic levels of violence and discrimination that transgender people face. The Administration’s first Statement of Administration Policy was in support of the Equality Act, and the White House has convened national leaders to discuss the importance of the legislation.
• Signing one of the most comprehensive Executive Orders on LGBTQI+ rights in history.  Within hours of taking office, President Biden signed an  Executive Order  which established that it is the official policy of the Biden-Harris Administration to prevent and combat discrimination against LGBTQI+ individuals, and to fully enforce civil rights laws to prevent discrimination on the basis of gender identity or sexual orientation. This Executive Order is one of the most consequential policies for LGBTQI+ Americans ever signed by a U.S. President. As a result of that Order, the Departments of Health and Human Services , Housing and Urban Development , Education , Consumer Financial Protection Bureau , and Justice have announced that they are expanding non-discrimination protections for transgender people in health care, housing, education, credit and lending services, and community safety programs.

Supporting transgender service members and veterans

• Reversing the discriminatory ban on transgender servicemembers.  In his first week in office, President Biden  signed  an Executive Order reversing the ban on openly transgender servicemembers serving in the Armed Forces, enabling all qualified Americans to serve their country in uniform. President Biden believes that an inclusive military strengthens our national security As a result of his Executive Order, the Department of Defense issued new  policies  which prohibit discrimination against transgender servicemembers, provide a path for transgender servicemembers to access gender-affirming medical care, and require that all transgender servicemembers are treated with dignity and respect.
• Supporting transgender veterans. To ensure that transgender veterans are treated with dignity and respect, the Department of Veterans Affairs (VA) launched an  agency-wide review  of its policies and practices to ensure that transgender veterans and employees do not face discrimination on the basis of gender identity or expression. In June, VA also announced that it is beginning the regulatory process to remove restrictions that prevent transgender veterans from accessing the gender-affirming care they need and deserve.

Responding to the crisis of anti-transgender violence and advancing safety

• Establishing a White House-led interagency working group on anti-transgender violence. To address the crisis of anti-transgender stigma and violence, during Pride Month in 2021 the White House established the first Interagency Working Group on Safety, Opportunity, and Inclusion for Transgender and Gender Diverse Individuals. The Working Group is co-led by the White House Domestic Policy Council and Gender Policy Council. To inform the priorities of the Working Group, throughout the fall of 2021 the White House convened 15 historic listening sessions with transgender and gender diverse people, advocates, and civil rights leaders from across the country and around the world, including a White House roundtable with transgender women of color .
• Releasing a White House report uplifting the voices of transgender people on gender-based violence and discrimination. On Transgender Day of Remembrance, the White House released a  report  sharing the perspectives from White House listening sessions, uplifting the voices and advocacy of transgender people throughout the country, and highlighting over 45 key, early actions the Biden-Harris Administration is taking to address the root causes of anti-transgender violence, discrimination, and denial of economic opportunity.
• Department of Justice civil rights enforcement actions. On September 14, 2021, the Department of Justice announced that it was launching a statewide civil investigation into Georgia’s prisons, which includes a focus on sexual abuse of transgender prisoners by other prisoners and staff. The Department of Justice’s Civil Rights Division and U.S. Attorney’s Office for the District of Puerto Rico also obtained a federal indictment charging three men with hate crimes for assaulting a transgender woman because of her gender identity.
• Ensuring non-discrimination protections in community safety programs. The Department of Justice issued a Memorandum from the Assistant Attorney General for Civil Rights regarding the application of Bostock v. Clayton County to the nondiscrimination provisions of the Safe Streets Act, the Juvenile Justice and Delinquency Prevention Act, the Victims of Crime Act, and the Violence Against Women Act to strengthen non-discrimination protections for transgender and LGBTQI+ individuals in key community safety programs.
• Strengthening protections for transgender individuals who are incarcerated. In January 2022 the Bureau of Prisons revised its manual on serving transgender offenders , improving access to gender-affirming care and access to facility placements that align with an inmate’s gender identity.
• Honoring those lost to violence.  The White House and the Second Gentleman of the United States hosted a first of its kind vigil in the Diplomatic Room of the White House to honor the lives of transgender and gender diverse people killed in 2021, and the countless transgender and gender diverse people who face brutal violence, harassment, and discrimination in the United States and around the world. The President also released a statement honoring the transgender people who lost their lives to violence.
• Advancing safety and justice for transgender and Two-Spirit Indigenous people. LGBTQI+ Native Americans and people who identify as transgender or “Two-Spirit” are often the targets of violent crimes. On November 15, 2021, President Biden signed an Executive Order on Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People. The Executive Order directs federal agencies to work hand in hand with Tribal Nations and Tribal partners to build safe and healthy Tribal communities to address the crisis of Missing and Murdered Indigenous People, including LGBTQI+ and “Two-Spirit” Native Americans.

Advancing health equity and expanding access to gender-affirming health care to support transgender patients

• Protecting transgender patients from health care discrimination. The Department of Health and Human Services (HHS) announced that it would interpret and enforce section 1557 of the Affordable Care Act’s prohibition on discrimination on the basis of sex in certain health programs to prohibit discrimination on the basis of gender identity and sexual orientation.
• Advancing gender-affirming care as an essential health benefit.  In 2021, the Centers for Medicare and Medicaid Services (CMS) approved the first ever application from a state to add additional gender-affirming care benefits to a state’s essential health benefit benchmark plan.
• Advancing health equity research on gender-affirming care.  The National Institutes of Health (NIH) announced that it will increase funding for research on gender-affirming procedures to further develop the evidence base for improved standards of care. Research priorities include a more thorough investigation and characterization of the short- and long-term outcomes on physical and mental health associated with gender-affirming care.
• Ending the HIV crisis among transgender and gender diverse communities.  In December, 2021, in recognition of World AIDS Day, the White House Office of National AIDS Policy released a revised National HIV/AIDS Strategy which now identifies transgender and gender diverse communities as a priority population in the federal government’s strategy to end the HIV epidemic.
• Advancing access to gender-affirming care through Ryan White HIV/AIDS Program. The Health Resources and Services Administration announced that it has released a letter encouraging Ryan White HIV/AIDS Program service providers to provide access to gender affirming care and treatment services to transgender and gender diverse individuals with HIV. The letter reaffirms the importance of providing culturally-affirming health care and social services as a key component to improving the lives of transgender people with HIV.
• Ensuring transgender patients can access birth control. In 2021 HHS issued a final rule to strengthen the Title X family planning program, fulfilling the Biden-Harris Administration’s commitment to restore access to equitable, affordable, client-centered, quality family planning services. The rule requires family planning projects to provide inclusive care to LGBTQI+ persons. Additionally, the rule prohibits discrimination against any client based on sex, sexual orientation, gender identity, sex characteristics, or marital status.

Supporting transgender students and their families

• Ensuring educational environments are free from sex discrimination and protecting LGBTQI+ students from sexual harassment.  President Biden signed an  Executive Order  recommitting the Federal Government to guarantee educational environments free from sex discrimination, including discrimination on the basis of sexual orientation or gender identity. The Executive Order charged the Department of Education with reviewing the significant rates at which students who identify as LGBTQ+ are subject to sexual harassment, including sexual violence. The Department of Education has announced that it intends to propose amendments to its Title IX regulations this year.
• Protecting the rights of transgender and gender diverse students. The Department of Education has affirmed that federal civil rights laws protect all students, including transgender and other LGBTQI+ students, from discrimination. The Department published a notice in the Federal Register announcing that it interprets Title IX’s statutory prohibition on sex discrimination as encompassing discrimination based on sexual orientation and gender identity.
• Department of Justice memorandum on Title IX. The Department of Justice issued a memorandum regarding the application of Bostock to Title IX.
• Speaking directly to transgender students. The Department of Justice, Department of Education, and Department of Health and Human Services issued a joint back to school message for transgender youth.
• Outreach and education to transgender and gender diverse students and their families. The Department of Education has published fact sheets and other resources showing the federal government’s support for transgender students, highlighting the ways schools can support students, reminding schools of their duty to investigate and address harassment based on sexual orientation or gender identity, and informing students how they can assert their rights and file complaints.
• Advancing research to address the harms of so-called conversion therapy.  The Substance Abuse and Mental Health Services Administration (SAMHSA) announced that it will update its 2015 publication  Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth  to reflect the latest research and state of the field. 

Promoting fair housing and ending homelessness for transgender Americans

• Advancing fair housing protections on the basis of gender identity. In February 2021 the Department of Housing and Urban Development (HUD) announced that it would administer and enforce the Fair Housing Act to prohibit discrimination on the basis of gender identity and sexual orientation.
• Ensuring safety and access to services for transgender people experiencing homelessness. In April, HUD withdrew the previous administration’s proposed “Shelter Rule,” which would have allowed for federally funded discrimination against transgender people who seek shelter housing. By withdrawing the previous administration’s proposed rule, the agency has restored protections for transgender people to access shelter in line with their gender identity. HUD has also released new tools for recipients to ensure compliance with these requirements in shelters and other facility settings.

Advancing economic opportunity and protections for transgender workers

• Ensuring nondiscrimination protections for transgender and gender diverse workers. In November 2021, the Department of Labor’s Office of Federal Contract Compliance Programs proposed to rescind the agency’s 2020 rule “Implementing Legal Requirements Regarding the Equal Opportunity Clause’s Religious Exemption,” an important step toward protecting workers from discrimination while safeguarding principles of religious freedom.
• Ensuring equal access to the workforce development system. The Department of Labor is enforcing discrimination prohibitions in workforce development programs funded by the Workforce Innovation and Opportunity Act, protecting workers from discrimination based on their gender identity or transgender status.

Advancing gender equity and transgender equality at home and around the world

• Advancing transgender equality in U.S. foreign policy and foreign assistance. In line with the Presidential Memorandum on Advancing the Human Rights of LGBTQI+ Persons Around the World , the United States is making significant investments to uphold dignity, equality and respect for transgender persons globally.  For example, USAID supports the Global Barometer for Transgender Rights and the LGBT Global Acceptance Index which track progress and setbacks to protecting transgender lives around the world.  The Department of Health and Human Services through the United States President’s Emergency Plan for AIDS Relief supports inclusive health care services for transgender individuals, enabling health clinics to provide care to the transgender community. And through the Department of State’s Global Equality Fund , local transgender rights organizations receive support to document human rights violations and provide critical legal assistance to community members.  
• Establishing the White House Gender Policy Council to Advance Gender Equity and Equality.  President Biden signed an  Executive Order  establishing the White House Gender Policy Council to advance gender equity and equality across the whole of the government, including by addressing barriers faced by LGBTQ+ people, in particular transgender women and girls, across our country.  

Supporting transgender leaders and public servants

• Making the Federal government a model employer for transgender public servants. President Biden signed an  Executive Order  which takes historic new steps to ensure the Federal government is a model employer for all employees – including transgender, gender non-conforming, and non-binary employees. The Executive Order charges agencies with building inclusive cultures for transgender employees by: expanding the availability of gender-neutral facilities in Federal buildings; ensuring that employee services support transgender employees who wish to legally, medically or socially transition; advancing the use of non-binary gender markers and pronouns in Federal employment processes; and expanding access to gender-affirming care and inclusive health benefits.
• Appointing historic transgender leaders. The Biden-Harris Administration includes barrier-breaking LGBTQI+ leaders, including Assistant Secretary for Health Dr. Rachel Levine, who is the first openly transgender person ever confirmed by the U.S. Senate. In October, she was also named a four-star admiral in the U.S. Public Health Service Commissioned Corps, becoming the first openly transgender person to hold that rank in any of the country’s uniformed services. Over 14 percent of Biden-Harris Administration appointees identify as LGBTQI+.

Advancing visibility for transgender Americans

• Issuing the First White House Proclamation for Transgender Day of Visibility.  On March 31, 2021 President Biden became the first U.S. President to issue a  proclamation  commemorating Transgender Day of Visibility.  
• Hosting a White House Virtual Convening on Transgender Equality.  In June, White House Press Secretary Jen Psaki hosted a first-of-its-kind  national conversation  on equality for transgender, gender non-conforming, and non-binary Americans.
• Releasing a toolkit on equality and inclusion for transgender Americans.  The White House released a new  toolkit  with best practices for advancing inclusion, opportunity, and safety for transgender Americans.
• Establishing a National Pulse Memorial. On June 25, 2021, President Biden signed H.R. 49 into law to designate the National Pulse Memorial. As the President acknowledged in his statement on the fifth anniversary of the Pulse nightclub shooting, we must acknowledge gun violence’s particular impact on LGBTQ+ communities across our nation, and we must drive out hate and inequities that contribute to the epidemic of violence and murder against transgender women – especially transgender women of color. As the President has said, Pulse Nightclub is hallowed ground.

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Youth Access to Gender Affirming Care: The Federal and State Policy Landscape

Lindsey Dawson , Jennifer Kates , and MaryBeth Musumeci Published: Jun 01, 2022

This analysis reflects the policy environment as of June 2020. Our newer tracker , provides a regularly updated overview of state policy restrictions on youth access to gender affirming care.

Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.

What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?

Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.

• Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14 th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14 th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11 th Circuit.
• Arkansas . In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14 th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14 th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1 st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ  argued that the Arkansas law  violates the Equal Protection Clause of the 14 th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8 th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal. 1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs. 2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
• Texas . In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation , a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
• Arizona . In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.

In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:

• criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
• penalize parents aiding in youth accessing gender-affirming care
• permit individuals to file for damages against providers who violate such laws
• limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services

Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.

What states have introduced protections related to sexual orientation and gender identity in health care?

Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:

• prohibitions on health insurance discrimination based on sexual orientation and/or
• requirements that state Medicaid programs explicitly cover health services related to gender transition

What is federal policy regarding gender-affirming services?

The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:

• On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
• On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the  Bostock  ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.

In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:

• Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
• Statement from Dept. of Health and Human Services (HHS) Sec. Becerra : Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
• Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
• Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
• The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
• It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.

OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.

What do major medical societies say about gender affirming services?

Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association , American Academy of Pediatrics , the Endocrine Society , American Psychological Association , American Psychiatric Association , and the World Professional Association for Transgender Health , among others , which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.

Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines , as does the World Professional Association for Transgender Health’s standards of care . Together these guidelines form the standard of care for treatment of gender dysphoria.

What are the implications of access restrictions?

State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:

LGBTQ+ youth : LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy , has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.

In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.

Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.

Parents : In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.

Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.

Teachers and others : In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.

Looking forward

The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.

These states include Alabama, Alaska, Arizona, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Tennessee, Texas, Utah, and West Virginia.

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These states include California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, and Washington.

Also of Interest

• LGBT+ People’s Health and Experiences Accessing Care
• The Health System Appears To Be Selling LGBT+ People Short
• The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health

Outlawing Trans Youth: State Legislatures and the Battle over Gender-Affirming Healthcare for Minors

Chapter One

• See full issue

As soon as I realized that I was not happy in my body, I went up to my parents to fix it. And it felt as natural as going up and being like, “Hey, I’m hungry.” I was just kind of like, “Hey, when’s the girl thing happening? ”

— Nicole Maines, actress and transgender activist, on coming out as transgender as a child 1

More than one-third of transgender high school students attempt suicide in a given year. 2 This alarming statistic underscores the importance of providing transgender youth 3 with access to medically necessary healthcare to bring their bodies into alignment with their gender identities. 4 Fortunately, medical science and understanding have advanced such that trans youth can safely and effectively transition under the supervision of medical professionals. 5 Obstacles remain, to be sure. 6 But information about, and access to, gender-affirming care for trans youth is more widespread than ever before. 7

Over the last few years, however, a growing political tide has threatened to reverse this progress. Gender-affirming healthcare 8 for minors has become a new frontier in the culture war. In the first months of 2020 alone, legislators in at least fifteen states introduced bills that would have prohibited and, in many cases, criminalized providing gender-affirming healthcare services to minors. 9 None of these bills became law. 10 But the fight over gender-affirming healthcare for minors is far from over; as of January 2021, at least nine states were considering gender-affirming care bans, 11 with more sure to follow, and a recent court decision in the United Kingdom effectively banning hormone treatments for trans youth under sixteen is likely to embolden the stateside opposition even further. 12 This Chapter shines light on attempts to outlaw necessary gender-affirming medical treatment for minors, drawing on scientific evidence and legal doctrine to show why such legislative efforts are harmful, prejudiced, and unconstitutional. Section A will outline the current medical standard of care for trans youth and argue that access to gender-affirming care provides critical and empirically demonstrable psychological, social, and legal benefits for trans youth. Section B will describe the 2020 bills, 13 critique their foundational premises, and analyze how their paternalistic narratives represent new rhetorical strategies of opposition to trans youth. Section C will offer two constitutional arguments against the bans, one based in the Equal Protection Clause and one based in parental due process rights.

The Importance of Gender-Affirming Healthcare for Trans Youth

The prevalence and availability of gender-affirming healthcare for trans youth have increased considerably since the 1990s, when transitioning before adulthood was quite rare. 14 A 2017 survey found that almost two percent of American public high school students in ten states and nine large urban school districts identified as transgender, 15 and although not all trans youth seek out gender-affirming healthcare, exponentially greater numbers of trans youth are pursuing this care. 16 This section describes the current medical standard of gender-affirming healthcare for trans youth and explains the importance of gender-affirming healthcare to the mental and social well-being and legal recognition of trans youth.

1. The Current Standard of Care.

The purpose of gender-affirming healthcare is usually to treat gender dysphoria (“dysphoria”), or “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth.” 17 Physical and social transition through the use of gender-affirming healthcare is clinically shown to reduce dysphoria by aligning a transgender person’s physical body and gender presentation with their gender identity. 18 Thus, every major U.S. medical association recognizes that gender-affirming healthcare is medically necessary treatment for dysphoria. 19

Gender-affirming healthcare for trans youth is typically admin-istered pursuant to Standards of Care published by the World Professional Association for Transgender Health (WPATH SOC), an international body of experts in transgender healthcare. 20 The WPATH SOC represent the authoritative medical consensus on treatment for dysphoria in transgender people. 21

The first step in gender-affirming treatment for trans youth is therapy and counseling. The WPATH SOC recommend that trans youth be diagnosed with gender dysphoria and referred by a gender therapist before they begin physical transition. 22 After the initial diagnosis, gender-affirming therapists help trans youth process their gender identities and cope with distress associated with dysphoria and coexisting sources of stress, and support them in taking future steps in physical and social transition. 23

Trans youth who are diagnosed with dysphoria sometimes begin hormone treatments, depending on their age and stage of physical development. Trans youth who have reached the early stages of puberty may be prescribed puberty blockers, which prevent the further progression of assigned-sex puberty and the development of associated secondary sex characteristics. 24 Halting puberty is typically done to give trans youth more time to process their identity and decide whether to pursue further steps in transition, 25 and to prevent irreversible physical changes that conflict with their desired gender presentation and increase dysphoria. 26

Beginning at around age sixteen, 27 trans youth can be prescribed hormone replacement therapy (HRT), which causes development of secondary sex characteristics associated with the trans youth’s identified gender. 28 For trans girls, HRT involves suppressing endogenous testosterone and taking estrogen, 29 a regimen that typically causes breast growth, softer skin, and reduction in body hair, 30 while for trans boys, it involves taking testosterone, 31 which typically causes muscle growth, an increase in body and facial hair, and a deeper voice. 32 Some nonbinary youth also seek HRT, but there are currently no formal standards of care for nonbinary people and there is little research as to clinical outcomes outside the binary context. 33 The WPATH SOC and Endocrine Society typically require parental consent before doctors may prescribe HRT to minors. 34

Gender confirmation surgery (GCS), which involves changing a transgender person’s reproductive anatomy to the anatomy usually associated with their identified gender, is rarely performed for trans youth because the WPATH SOC require the patient to have attained the age of majority to be eligible for surgery. 35 Additionally, insurance coverage usually requires GCS patients to be eighteen or older. 36 However, GCS is not the only type of gender-affirming surgery. Transgender men may undergo surgery to remove breast tissue (“top surgery”), and the WPATH SOC allow this surgery to be performed on patients under eighteen on a case-by-case basis. 37

2. Why Trans Youth Need Access to Gender-Affirming Healthcare .

Access to these gender-affirming healthcare services is essential — even lifesaving — for trans youth. There is a vast disparity in traditional measures of quality of life between trans youth with untreated dysphoria and their cisgender peers. A wealth of empirical research confirms that, although it does not erase this gap, medical transition narrows it considerably. This section summarizes the benefits of gender-affirming care for trans youth in three spheres: mental health, social acceptance, and legal rights. Although they are categorized separately for organizational purposes, these spheres often intersect and complement one another in practice.

(a) Mental Health. — Untreated dysphoria in trans youth is associated with severe mental health problems, including depression, social anxiety, and suicidal thoughts and behavior. 38 A study of baseline (pre-transition) psychological characteristics of trans youth revealed that twenty percent had “moderate to extreme” depressive symptoms, and that their reported rate of suicidal thoughts and attempts was at least three times higher than that of the general youth population. 39 Over half reported having thought about suicide, and a third reported at least one attempt. 40

Conversely, a large body of research demonstrates that trans youth who receive gender-affirming healthcare to treat their dysphoria show decreased anxiety, depression, suicidal behavior, and psychological distress, 41 and increased quality of life. 42 Trans children who are allowed to socially transition before puberty have relatively normal rates of depression and anxiety, “in striking contrast” with nontransitioned trans children. 43 A longitudinal study of trans adolescents before and after they received gender-affirming care found that psychological functioning steadily improved throughout treatment and that overall well-being after treatment was “comparable to [that of] same-age peers.” 44 And a study of transgender adults found that subjects who had received puberty blockers in childhood had a significantly lower incidence of suicidal ideation than did those who had wanted puberty blockers but did not receive them. 45 Of course, gender dysphoria is not the sole cause of psychological distress and mental health problems in trans youth, nor is access to gender-affirming healthcare a panacea. But, in the words of the preeminent professional association of pediatric psychiatry in the United States, “[r]esearch consistently demonstrates that gender diverse youth . . . have better mental health outcomes” when they have access to gender-affirming healthcare. 46

(b) Social Integration. — Middle school and high school are stressful for many young people, but they are often particularly difficult social environments for trans youth. Not only are trans students disproportionately bullied and alienated by their peers, 47 but they may also have problems fitting in due to the frequent mental health issues associated with untreated dysphoria 48 and feelings of not “belonging” with cisgender students. 49 This trauma only intensifies with the onset of assigned-sex puberty, which causes trans youth to develop secondary sex characteristics (such as breasts in trans boys and facial hair in trans girls) that are inconsistent with their gender identities. 50 Because of this process, trans youth who undergo assigned-sex puberty often experience decreased self-esteem and increased body image issues, which can cause further social and educational impairment. 51 Physical changes from puberty may also make it harder for trans youth to “pass” as the gender with which they identify, 52 meaning they are more likely to experience psychological problems 53 and to face discrimination and abuse. 54

Puberty blockers and HRT allow trans youth to avoid many of these challenges. Trans youth who start puberty blockers or HRT in childhood or adolescence are spared the hardships of navigating school and peer relationships while presenting as a gender with which they do not identify. Because of this relief, medically transitioned trans youth are often more confident and socially well-adjusted than their nontransitioned peers. 55 Undergoing medical transition at an earlier age also allows many trans youth to “pass” more easily as their identified gender, 56 and avoid many of the challenges associated with being visibly transgender. 57

(c) Legal Status. — Gender-affirming medical care often mediates the availability of legal rights and protections for trans youth. Most notably, many states require medical evidence like a diagnosis of gender dysphoria, HRT, or GCS to change a transgender person’s gender on identity documents such as driver’s licenses and birth certificates. 58 Misalignment between a trans youth’s gender presentation and their gender on identity documents is not an isolated indignity; it can have serious collateral consequences. For example, many colleges and universities do not allow students to use their preferred names or genders in school records if they have not legally changed them on identity documents. 59

Access to gender-affirming care is also critical for many trans youth to participate in competitive school sports. The National Collegiate Athletic Association and some state high school athletic associations allow trans girls to play on girls’ sports teams only after they have taken HRT for a certain period, out of concern that their assigned sex gives them an “unfair” advantage. 60 Trans boys typically do not have to meet specific medical criteria in order to play on boys’ teams, 61 but in practice it will often be difficult for trans boys to compete with other boys without the physiological benefits of testosterone. 62

Finally, lack of access to gender-affirming care continues to mitigate trans youths’ access to sex-segregated school bathrooms and locker rooms. The Biden Administration is expected to reinstate the Obama Administration’s 2016 Title IX guidance that required schools to allow students to use facilities consistent with their gender identities. 63 Even so, there are reasons to think access to gender-affirming medical care is still relevant to determining trans youths’ access to such facilities. First, trans youth may be less comfortable coming out as transgender to their peers and school officials if they have not started medical transition. Second, school districts and courts may be more willing to accept in practice a trans student’s use of facilities consistent with their identified gender if they have provided evidence of being diagnosed with dysphoria or undergoing gender-affirming medical treatment. 64

Proposed State Legislation Banning Gender-Affirming Healthcare for Trans Youth

1. background and legislative context..

A custody battle in a Dallas suburb is an unlikely spark for a political brushfire. But in October 2019, a dispute in Texas family court over parental rights for a seven-year-old transgender girl ignited outrage in conservative circles. 65 The girl’s father, Jeffrey Younger, petitioned for full custody based on his disagreement with her mother’s gender-affirming parenting approach, accusing the mother of “emotional abuse” for allowing the girl to express her gender identity. 66 Unfolding amid a frenzy of media coverage and vocal opposition to the mother’s gender-affirming stance from conservatives, 67 the Younger case shined a national spotlight on the issue of gender-affirming medical care for minors and prompted calls for legislative action from Texas Republicans. 68

In truth, the Younger case and the ensuing media controversy did not begin the political movement against gender-affirming healthcare for minors so much as add fuel to a campaign already broiling within conservative lobbying groups. The Heritage Foundation, one of the most influential conservative think tanks in the United States, 69 hosted a series of events on the “medical risks” of gender-affirming healthcare for trans youth at its DC headquarters throughout 2019. 70 These events proved foundational to later legislative efforts; attendees at the conferences authored several of the bans, 71 and a policy manager at Family Policy Alliance, a Christian conservative lobbying group that cohosted one of the Heritage events, confirmed that her organization “work[ed] with legislators all over the country” to distribute “model” gender-affirming care bans to be introduced during states’ 2020 legislative sessions. 72

With help from these groups, legislators in fifteen states introduced bills between January and March 2020 banning medical professionals from providing gender-affirming healthcare to minors. 73 The bills are tellingly similar in substance and language. 74 Almost every bill (with some minor deviations 75 ) bans all medical professionals in the state from administering puberty blockers or HRT to, or performing gender-affirming surgery on, anyone under the age of eighteen, with notable exceptions for minors with “medically verifiable” developmental disorders or intersex conditions. 76 Most of the proposals make providing gender-affirming care a crime; on the extreme end, violation of Idaho’s prohibition is a felony punishable by a life sentence. 77 Because they would prevent any state-licensed medical providers from administering gender-affirming care, the bans would effectively prohibit trans youth from accessing that care unless they were able to travel out of state. Thus, they would disproportionately burden trans youth from disadvantaged socioeconomic backgrounds and communities of color, who are less likely to have the resources to travel across state lines or to relocate for care. 78

None of the fifteen bills introduced in early 2020 became law, 79 al-though bills in Alabama and South Dakota passed by large margins in individual state houses. 80 But the fact that no bills passed during the 2020 legislative session may not be a meaningful indication of whether they will pass in the future. The COVID-19 lockdowns in the United States in March 2020 forced many state legislatures to adjourn regular sessions before important committee votes on the bills. 81 Additionally, a wave of early failures does not necessarily rule out future success; “bathroom bills” banning trans people from using public bathrooms and changing facilities consistent with their identified genders failed in at least ten states between 2013 and 2015 82 before North Carolina infamously passed House Bill 2 in March 2016. 83 Finally, a recent High Court decision in the United Kingdom severely inhibiting administration of puberty blockers to trans youth under age sixteen is likely to invigorate opponents of gender-affirming care for trans youth in the United States. 84

2. Explaining Gender-Affirming Healthcare Bans.

Legal and political battles over gender-affirming healthcare have persisted for decades, 85 and are somewhat ubiquitous today. 86 Nevertheless, the gender-affirming care bans deserve particular attention because they mark a subtle yet important rhetorical pivot in the broader political opposition to trans youth. To understand the larger sociopolitical significance of the gender-affirming care bans, as well as to lay the foundation for constitutional arguments against them, this section deconstructs the bans’ underlying purposes and rationales.

Some of the bills included statements of legislative purpose that provide useful starting points. For example, the Mississippi Senate bill’s “Legislative findings and intent” section states in part that “the decision to pursue [gender-affirming care] should not be presented to or determined for minors who are incapable of comprehending the negative implications and life-altering difficulties attending to these interventions.” 87 Similar language subsists throughout the proposals, revealing a consistent, surface-level legislative intent to “protect” trans youth from gender-affirming medical interventions. 88

This paternalistic rhetoric represents a narrative shift that has surfaced in the wake of widespread rejection of preexisting justifications for discrimination against trans youth. The most prominent political crusade against trans youth, the bathroom scare of the mid-to-late 2010s, portrayed trans youth as predatory, deviant, and mentally unstable, 89 and their rights to use sex-segregated spaces as intrusions on the privacy and safety of cisgender children. 90 These strategies have largely failed both in courts of law 91 and in the court of public opinion. 92 Even many conservatives have cautioned that overt fearmongering about trans people intruding on others in public spaces is not a winning political strategy. 93

But prejudice dies hard. When one justification for negative treatment of a disfavored group falls out of favor with the public or the legal system, opponents of that group often translate their prejudice into new rhetorical forms that are more palatable. 94 The shift from the stigmatization and vilification of trans youth in the bathroom bills to the victimization narrative embodied in the gender-affirming care bans illustrates how opponents of trans identity are adapting their rhetoric in response to changing legal and social attitudes towards transgender children. Courts, media, and the public should not be fooled. The paternalistic arguments underlying gender-affirming care bans reflect the same underlying prejudices arising from the same individuals and groups, 95 and are directed towards the same ends — erasing trans youth by stigmatizing transgender identity and fortifying the gender binary 96 — as bathroom bills and similar transparently vindictive campaigns. In translating their hostility to trans youth into a more socially acceptable language of “protecting” trans youth from the supposedly fraught choice of whether to transition, 97 cultural conservatives play both sides of the ball. They moderate their image by appealing to fundamental paternalistic impulses while continuing to work toward eradication of transgender identity in children by blocking access to medical services that make transition possible. 98

Their pretextual nature does not — as the UK case illustrated 99 — mean the paternalistic justifications can be ignored. The argument that trans youth should not receive gender-affirming medical care must be vigorously discredited on its own terms as a fallacious rationalization of ingrained prejudices that contradicts both empirical data and the experiences of thousands of children. For one thing, the bills’ central justification, that trans youth lack the capacity for self-reflection necessary to accurately perceive their gender identities, 100 is flatly untrue. Trans youth are quite secure in their gender identities by the time hormonal interventions become physiologically appropriate. 101 A related claim, that trans youth should have to wait until adulthood to transition because many young children who display gender nonconforming behavior “desist,” or do not grow up to be transgender, 102 has questionable empirical support 103 and, more fundamentally, equivocates gender expression with gender identity. There is a meaningful difference between a child who exhibits gender-atypical behavior and a child who persistently identifies as another gender, and the fact that the former child may not be transgender does nothing to invalidate the latter child’s entitlement to access medically necessary gender-affirming care. And gender nonconforming children who later “desist” from expressing the binary gender opposite to their assigned sex may not necessarily identify as cisgender; they may be nonbinary or possess another gender identity. Presuming that all of these persons are cisgender thus erases nonbinary experiences. 104 Second, the implied premise that trans youth have unilateral control over whether and when they transition is empirically untrue because the current standards of care recommend both parental consent and a medical diagnosis of gender dysphoria before a minor can receive puberty blockers or HRT. 105 This “gatekeeping” model, far from uncritically acceding to trans youths’ wishes, privileges caution and deliberation over ease of access. 106 Finally, even if one accepts that a certain number of cisgender youth will mistakenly transition if gender-affirming healthcare is available (which is itself a dubious proposition), that number is likely dwarfed by the number of trans youth who will suffer the opposite, equivalent harm — being unable to transition even though transition is right for them — if gender-affirming healthcare is not available.

Constitutional Arguments Against Gender-Affirming Care Bans

Gender-affirming care bans are not only harmful and founded on false premises, they are also unconstitutional. This section sketches two constitutional arguments against these proposed bans: one based in the Equal Protection Clause of the Fourteenth Amendment, and one based in the parental rights strand of substantive due process jurisprudence.

1. Equal Protection.

The Equal Protection Clause ensures the right of all citizens to enjoy “the equal protection of the laws,” 107 or to be free from unjustified, government-imposed discrimination. 108 An equal protection challenge against a facially discriminatory law usually proceeds in two stages: First, the plaintiff must show that the law discriminates or classifies based on the plaintiff’s membership in a protected class. 109 Second, the burden shifts to the government to show that the classification is justified by an adequate government interest, and the extent of the government’s burden depends on the tier of scrutiny applied to the type of classification at issue. 110

(a) Protected Class. — In the last few years, a growing number of courts of appeals have found that discrimination against transgender people violates equal protection. 111 Some courts have held that transgender status is a protected class in its own right, 112 while others have found that antitransgender discrimination is sex discrimination. 113 Across-the-board bans on gender-affirming healthcare for trans youth would likely receive heightened scrutiny under either framing. Gender-affirming care bans discriminate based on transgender status because they prohibit providing HRT and GCS to minors for the specific purpose of affirming a trans youth’s gender identity, thus facially discriminating against transgender identity, and because in most cases they include exceptions allowing that same care to be provided to cisgender minors for the purpose of treating intersex conditions or “disorder[s] of sexual development.” 114 It may be argued that the bans do not facially discriminate based on transgender status, because they simply bar conduct associated with being transgender . But this formalistic status/conduct distinction was hardly convincing in the context of sexual orientation discrimination and is similarly unpersuasive in the context of antitransgender discrimination. 115

The per se transgender status argument may no longer be necessary, however, in light of the Supreme Court’s recent decision in Bostock v. Clayton County , 116 which held that discrimination against transgender people is sex discrimination under Title VII. 117 Justice Gorsuch’s majority opinion applied a but-for causation standard to find that “discrimination based on . . . transgender status necessarily entails discrimination based on sex.” 118 Although Bostock ’s holding formally reached only Title VII, Justice Alito’s dissent and several courts of appeals recognized that its analysis applies just as clearly to equal protection claims. 119 Just as an employer discriminates “because of sex” when it “intentionally penalizes a person [assigned] male at birth for traits or actions that it tolerates in an employee [assigned] female at birth,” 120 bans on gender-affirming care for minors discriminate because of sex when they deny minors assigned one sex at birth access to certain medical procedures for gender-affirming purposes, but allow those same procedures to be performed for minors assigned the other sex at birth for non-gender-affirming purposes. 121

(b) Government Interest. — To survive heightened scrutiny, the government’s interest must at least be “important” and the law must be “substantially related” to the advancement of the interest. 122 Gender-affirming care bans fail this means-ends inquiry along both dimensions. First, the alleged purpose of the bans — to protect children from receiving gender-affirming healthcare — is fundamentally inconsistent with the empirical evidence and the lived experiences of many trans youth showing the efficacy and safety of these treatments, 123 and is based in faulty logic. 124 It is hard to argue that “protecting” children from medically necessary healthcare that is endorsed by nearly every professional medical association in the country 125 and validated by a near-unanimous consensus in peer-reviewed literature 126 is an interest sufficiently “legitimate” to pass rational basis review, much less one “important” enough to satisfy heightened scrutiny. 127 Second, the bans fail the “substantially related” test because they are considerably underinclusive: even as they identify gender-affirming medical interventions as “dangerous and uncontrolled human medical experiment[s],” 128 they allow the same procedures to be performed on children who have “medically verifiable disorder[s] of sex development.” 129 If the bans are actually motivated by concern over the supposed dangers of puberty blockers, HRT, and GCS, providing an exception allowing those treatments to be performed for practically any medical condition other than gender dysphoria 130 is hardly “substantially related” to abating these alleged harms.

If their purposes are taken at face value, the gender-affirming care bans cannot survive heightened scrutiny. But they also fail under rational basis review, since, as section A explained, their real purpose is preventing transgender children from expressing their transgender identity, 131 an expression of animus against transgender people that cannot be a legitimate government interest in the first place. 132 Animus can be demonstrated in a number of ways: based on inference from the structure of the law and through direct evidence that the law was motivated by prejudice. 133 As the Supreme Court held in City of Cleburne v. Cleburne Living Center, Inc ., 134 the structure of a classification can provide inferential evidence of animus when the alleged government interest does not support targeting the particular group over and above other similarly situated groups. 135 Thus, when state governments profess that bans on gender-affirming medical treatments are meant to protect children from invasive and life-changing medical procedures, but only ban procedures that are performed for the purpose of affirming a trans youth’s gender identity, the arbitrariness of the classification suggests the stated interests are pretext for animus. 136

Ultimately, however, this structural analysis is probably unneeded because there is abundant direct evidence of animus against transgender people surrounding the bans. 137 For example, during a private meeting, the Florida bill’s sponsor told a nonbinary opponent of the bill that transgender people “manufacture” their identities. 138 The author of the South Dakota legislation labeled medical transition in minors a “crime against humanity” and analogized it to medical experimentation at Auschwitz. 139 The lead sponsor of the Colorado bill admitted he was “not concerned” about the potential impact of the bill on the mental health of trans youth in the state, but was disturbed by “a progression of acceptance of young kids being sterilized.” 140 The organizations that promoted these bills also demonstrate clear animus towards transgender identity. YouTube removed the video of the October 2019 Heritage Foundation event that inspired many of the bills after determining that the Heritage panelists’ incendiary comments violated the YouTube hate speech policy. 141 And the Family Policy Alliance, which helped draft many of the bills, declares prominently on its website that it “oppose[s] . . . attempts to normalize” being transgender, “especially amongst impressionable children.” 142

2. Due Process and Parental Rights.

The gender-affirming care bans also arguably violate the Fourteenth Amendment’s due process guarantee of parents ’ rights to make decisions about the upbringing of their children. The due process right to freedom in child rearing is one of the foundational rights protected under substantive due process doctrine, dating back to the early twentieth century 143 and consistently reaffirmed since then. 144 It protects parents’ ability to make important decisions about “the care, custody, and control of their children” free from government interference, 145 based on the presumption that a parent, not the state, is in the best position to determine their child’s best interests. 146 The Supreme Court has never explicitly held that the due process right to freedom in child rearing encompasses the right to direct a child’s medical care, but has implied as much in at least one case. 147 Many other courts and commentators have presumed that parents’ common law right to supervise their children’s healthcare is constitutionally protected. 148 Gender-affirming care bans would likely violate this right. Prohibiting parents from authorizing medically necessary treatment for their children when they believe this care is in their children’s best interests is just the kind of intrusive government conduct that parental due process rights guard against.

Of course, parental rights are not absolute. The state can limit parental autonomy in medical decisionmaking in order to prevent injury to children’s health and well-being. 149 For example, many states have passed bans on conversion therapy for minors based on the nearly unanimous medical consensus that such treatment is harmful and dangerous. 150 Courts have upheld these bans against due process challenges on the ground that “the fundamental rights of parents do not include the right to choose . . . a specific medical or mental health treatment that the state has reasonably deemed harmful.” 151

The test is whether the treatment is actually harmful or reasonably believed to be harmful, which depends on the weight of scientific evidence for the legislature’s judgment. Conversion therapy bans do not violate due process because a considerable scientific consensus views conversion therapy as harmful and senseless. 152 The crucial difference in the case of gender-affirming care bans is that the weight of the scientific supermajority, 153 along with a growing canon of empirical research 154 and the lived experiences of thousands of trans youth who benefit from gender-affirming care, is against the legislatures’ judgments that gender-affirming care is harmful.

None of this is to say that challenges to gender-affirming healthcare bans on due process grounds are certain to prevail. Courts often fail to interrogate the factual underpinnings of a legislature’s judgment because their focus is more directly trained on rooting out the motivations of the legislature than on checking the lawmakers’ work in an empirical sense, 155 or because they are distracted by their moral preconceptions of an issue. 156 This failure is unfortunately commonplace in transgender rights cases, 157 though recent decisions have shown improvement in this regard. 158 There is also a risk that parental due process arguments could be turned against trans youth who seek to use state resources to obtain access to gender-affirming care against the wishes of unaccepting parents. Detailed exploration of this question is not possible here, but it is doubtful that the best-interests presumption applies if the parent’s decision not to accept their child’s transgender identity or desire to transition is motivated by prejudice, to which “the law cannot, directly or indirectly, give . . . effect.” 159

Anxiety about gender-affirming medical interventions for trans youth is understandable in many respects. Puberty blockers, HRT, and GCS are dramatic and life-changing decisions. However, a failure to intervene can be equally consequential. In other words, foregoing gender-affirming care “is not a neutral option” 160 for trans youth: it is a choice that imposes significant risks of physical, mental, social, and legal harms. Even so, this Chapter does not argue that every trans youth must transition before adulthood. Although evidence suggests this is the best option in many cases, every trans youth is different, and many transgender people live happy and healthy lives after transitioning as adults. Nor does this Chapter have the scope to opine on the ideal distribution of agency in these decisions between doctors, parents, and trans youth, beyond the observation that parents’ animus or prejudice against transgender people should not inhibit a youth’s access to care. 161 Ultimately, “protecting” trans youth requires allowing them to access medical care that permits them to live according to their own definitions of themselves, rather than the definitions ascribed to them by politicians whose goal is not protection, but suppression of children whose identities threaten their worldview. Perhaps lawmakers will one day realize this. But for now, the issue of gender-affirming healthcare for trans youth remains a heated battleground in the culture war, with the rights of thousands of children once again subject to political will.

^ Pam O’Brien, How Nicole Maines Is Paving the Way for the Next Generation of LGBTQ Youth , Shape (Aug. 15, 2019), <a href=" https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl ">https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl">https://www.shape.com/celebrities/interviews/nicole-maines-transgender-activist-supergirl [ https://perma.cc/5QET-8948 ].

^ See Michelle M. Johns et al., Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017 , 68 Morbidity & Mortality Wkly. Rep . 67, 70 (2019).

^ Hereinafter “trans youth,” which this Chapter defines as transgender children and adolescents between roughly twelve and eighteen years of age.

^ This Chapter assumes basic familiarity with terms like “transgender” and “cisgender” and with the difference between assigned sex at birth and gender identity. For an introductory explanation of these concepts, see Understanding Gender , Gender Spectrum , <a href=" https://genderspectrum.org/articles/understanding-gender ">https://genderspectrum.org/articles/understanding-gender">https://genderspectrum.org/articles/understanding-gender [ https://perma.cc/U635-823E ].

^ See Jason Rafferty, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents , Pediatrics , Oct. 2018, at 1, 4–5.

^ See generally, e.g ., Emily Ikuta, Note, Overcoming the Parental Veto: How Transgender Adolescents Can Access Puberty-Suppressing Hormone Treatment in the Absence of Parental Consent Under the Mature Minor Doctrine , 25 S. Cal. Interdisc. L.J. 179 (2016) (describing the problems that arise when the parent of a trans youth refuses to provide consent to gender-affirming treatment for their child, and how minors can argue for the right to consent).

^ See, e.g ., Diane Ehrensaft, Gender Nonconforming Youth: Current Perspectives , 8 Adolescent Health Med. & Therapeutics 57, 57–58 (2017). This increased research and attention has largely centered on the experiences of youth who transition from one binary gender to the other, and has neglected the experiences of nonbinary youth. Abbie E. Goldberg et al., Health Care Experiences of Transgender Binary and Nonbinary University Students , 47 Counseling Psych . 59, 86 (2019). For more on the experiences of nonbinary youth in transgender healthcare, see, for example, Gary E. Butler, Child and Adolescent Endocrinology , in Genderqueer and Non-binary Genders 171, 177–79 (Christina Richards, Walter Pierre Bouman & Meg-John Barker eds., 2017); and Goldberg et al., supra , at 86–90.

^ This Chapter uses the umbrella term “gender-affirming healthcare” to describe the range of medical services that trans youth use to bring their bodies and lived experiences into alignment with their gender identities (“transition”).

^ See Past Legislation Affecting LGBT Rights Across the Country , ACLU (Mar. 20, 2020), https://www.aclu.org/past-legislation-affecting-lgbt-rights-across-country-2020 [ https://perma.cc/KQ6T-KDR2 ] [hereinafter ACLU Legislation Tracker ]; H.B. 3515, 101st Gen. Assemb., Reg. Sess. (Ill. 2019). The Illinois bill was originally introduced in 2019, but changed sponsors in 2020. See Bill Status of HB 3515 , Ill. Gen. Assembly , https://www.ilga.gov/legislation/BillStatus.asp?DocNum=3515&GAID=15&DocTypeID=HB&SessionID=108&GA=101 [ https://perma.cc/6S5R-6SX9 ].

^ See ACLU Legislation Tracker , supra note 9; Bill Status of HB 3515 , supra note 9.

^ See H.B. 1, 2021 Leg., Reg. Sess. (Ala. 2021); S.B. 224, 122d Gen. Assemb., 1st Reg. Sess. (Ind. 2021); H. File 193, 89th Gen. Assemb., Reg. Sess. (Iowa 2021); H.B. 33, 101st Gen. Assemb., 1st Reg. Sess. (Mo. 2021); H.B. 113, 67th Leg., Reg. Sess. (Mont. 2021); H.B. 68, 167th Gen. Ct., Reg. Sess. (N.H. 2021); S.B. 676, 58th Leg., 1st Reg. Sess. (Okla. 2021); H.B. 92, 64th Leg., Gen. Sess. (Utah 2021); H.B. 68, 87th Leg., Reg. Sess. (Tex. 2020). For an up-to-date list of gender-affirming care bans filed in 2021, see Legislative Tracker: Anti-transgender Medical Care Bans , Freedom for All Ams ., <a href=" https://freedomforallamericans.org/legislative-tracker/medical-care-bans ">https://freedomforallamericans.org/legislative-tracker/medical-care-bans/">https://freedomforallamericans.org/legislative-tracker/medical-care-bans [ https://perma.cc/JX3V-J3US ].

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 [151] (Eng.).

^ Because the rationales and legal errors underlying the 2021 bills were substantially the same as the 2020 bills, and because the 2021 bills were rapidly evolving and changing at the time of publication, this Chapter focuses its critique on the 2020 bills rather than the 2021 bills.

^ See, e.g ., Hallie Horowitz, Introduction to Just Evelyn, Mom, I Need to Be a Girl 4, 4 (1998), <a href=" https://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf ">http://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf">https://ai.eecs.umich.edu/people/conway/TS/Evelyn/Mom_I_need_to_be_a_girl.pdf [ https://perma.cc/LD34-7MYX ] (describing “one of the first” adolescent transitions in the mid-1990s).

^ Johns et al., supra note 2, at 68. 1.6 percent said they were “not sure.” Id .

^ See Ehrensaft, supra note 7, at 57–58.

^ World Pro. Ass’n for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People 5 (7th ed. 2012) [hereinafter WPATH SOC]. Importantly, dysphoria is a psychological condition that results from a difference between gender identity and assigned sex at birth; transgender identity is not itself a psychological condition or mental illness. See id . at 5–6.

^ See id . at 8.

^ Kellan E. Baker, The Future of Transgender Coverage , 376 New Eng. J. Med. 1801 , 1801 (2017); see Professional Organization Statements Supporting Transgender People in Health Care , Lambda Legal (Sept. 17, 2018), https://www.lambdalegal.org/sites/default/files/publications/downloads/resource_trans-professional-statements_09-18-2018.pdf [ https://perma.cc/5HTA-PUHR ] (collecting statements of medical necessity). “Medically necessary” — and the closely related term “medical necessity” — is a term of art used to describe “[h]ealth care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.” Medically Necessary , HealthCare.gov , <a href=" https://www.healthcare.gov/glossary/medically-necessary ">https://www.healthcare.gov/glossary/medically-necessary/">https://www.healthcare.gov/glossary/medically-necessary [ https://perma.cc/Y6K7-HAKL ].

^ See WPATH SOC, supra note 17, at 1–2; Rafferty, supra note 5, at 6. Other medical associations also provide guidance to clinicians in specific areas of care such as hormone treatment. See, e.g ., Wylie C. Hembree et al., Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline , 102 J . Clinical Endocrinology & Metabology 3869, 3874 (2017).

^ See Am. Med. Ass’n House of Delegates, Resolution: 122, Subject: Removing Financial Barriers to Care for Transgender Patients 1 (2008), <a href=" https://www.imatyfa.org/assets/ama122.pdf ">http://www.imatyfa.org/assets/ama122.pdf">https://www.imatyfa.org/assets/ama122.pdf [ https://perma.cc/T6RY-7LZN ]; Edmo v. Corizon, Inc., 935 F.3d 757, 769 (9th Cir. 2019) (citing case law and medical authority recognizing the WPATH SOC as the prevailing medical standard).

^ See WPATH SOC, supra note 17, at 14, 18–19.

^ See Johanna Olson, Catherine Forbes & Marvin Belzer, Management of the Transgender Adolescent , 165 Archives Pediatric & Adolescent Med . 171, 174 (2011) (stating that the majority of gender specialists follow this affirming approach); Leigh A. Spivey & Laura Edwards-Leeper, Future Directions in Affirmative Psychological Interventions with Transgender Children and Adolescents , 48 J. Clinical Child & Adolescent Psych . 343, 347–48 (2019).

^ See Simone Mahfouda et al., Review, Puberty Suppression in Transgender Children and Adolescents , 5 Lancet Diabetes & Endocrinology 816, 817–18 (2017).

^ Id . at 816; see WPATH SOC, supra note 17, at 19.

^ See WPATH SOC, supra note 17, at 19; Mahfouda et al., supra note 24, at 817–18.

^ See Hembree et al., supra note 20, at 3884–85.

^ See WPATH SOC, supra note 17, at 33–34.

^ Id . at 48.

^ Id . at 38 tbl.1B.

^ Id . at 49.

^ Id . at 37 tbl.1A.

^ See Butler, supra note 7, at 179; Anna Martha Vaitses Fontanari et al., Gender Affirmation Is Associated with Transgender and Gender Nonbinary Youth Mental Health Improvement , 7 LGBT Health 237, 243 (2020).

^ See WPATH SOC, supra note 17, at 20; Hembree et al., supra note 20, at 3878 tbl.5. But see generally Ikuta, supra note 6 (describing a strategy for minors in the United States to obtain HRT without parental consent).

^ See WPATH SOC, supra note 17, at 21, 54–55; see also Olson, Forbes & Belzer, supra note 23, at 176.

^ See, e.g ., Clinical Policy Bulletin, Gender Affirming Surgery , Aetna (Jan. 12, 2021), <a href="https://www.aetna.com/cpb/medical/data/600_699/0615.html ">https://www.aetna.com/cpb/medical/data/600_699/0615.html [ https://perma.cc/C5ZK-VZAR ].

^ WPATH SOC, supra note 17, at 21; see also Masculinizing Chest Reconstruction (“Top Surgery”) , UCSF Transgender Care , <a href=" https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery ">https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery/">https://transcare.ucsf.edu/masculinizing-chest-reconstruction-top-surgery [ https://perma.cc/6HM2-UV5W ].

^ See, e.g ., Trevor Project, National Survey on LGBTQ Youth Mental Health 2020 , at 3 (2020), <a href=" https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf ">https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf">https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf [ https://perma.cc/WXM5-JVG6 ]; Johanna Olson et al., Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria , 57 J. Adolescent Health 374, 375, 378 tbl.5 (2015).

^ Olson et al., supra note 38, at 379.

^ Id .; see also Johns et al., supra note 2, at 69 tbl.2 (finding that 43.9% of transgender high school students considered attempting and 34.6% attempted).

^ See, e.g ., Rosalia Costa et al., Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria , 12 J. Sexual Med . 2206, 2212 (2015); Annelou L.C. de Vries et al., Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment , Pediatrics , Oct. 2014, at 1, 6–7; Fontanari et al., supra note 33, at 243; Kristina R. Olson et al., Mental Health of Transgender Children Who Are Supported in Their Identities , Pediatrics , Mar. 2016, at 1, 5; Jack L. Turban et al., Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation , Pediatrics , Feb. 2020, at 1, 5; Anna I.R. van der Miesen et al., Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared with Cisgender General Population Peers , 66 J. Adolescent Health 699, 703 (2020).

^ See de Vries et al., supra note 41, at 7. See generally What Does the Scholarly Research Say About the Effect of Gender Transition on Transgender Well-Being? , Cornell Univ.: What We Know Project , <a href=" https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people ">https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people">https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people [ https://perma.cc/RZ6H-4JC8 ] [hereinafter What We Know Project ] (collecting over fifty studies showing improvements in quality of life for transgender people after gender-affirming care).

^ Lily Durwood, Katie A. McLaughlin & Kristina R. Olson, Mental Health and Self-Worth in Socially Transitioned Transgender Youth , 56 J. Am. Acad. Child & Adolescent Psychiatry 116, 116 (2017).

^ de Vries et al., supra note 41, at 7 (finding that transitioned youth exhibited “quality of life, satisfaction with life, and subjective happiness” scores similar to those of cisgender youth).

^ See Turban et al., supra note 41, at 5.

^ AACAP Statement Responding to Efforts to Ban Evidence-Based Care for Transgender and Gender Diverse Youth , Am. Acad. Child & Adolescent Psychiatry (Nov. 8, 2019), <a href=" https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx ">https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx">https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx [ https://perma.cc/WXH9-5AKY ] [hereinafter AACAP Statement ]; see also Endocrine Soc’y & Pediatric Endocrine Soc’y, Transgender Health Position Statement (2020), <a href=" https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf ">https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf">https://www.endocrine.org/-/media/endocrine/files/advocacy/position-statement/position_statement_transgender_health_pes.pdf [ https://perma.cc/JQ9S-TAQ2 ].

^ See, e.g ., Johns et al., supra note 2, at 69 tbl.2 (showing significantly higher rates of in-person and online bullying and feelings of unsafety at school compared to cisgender students); cf . Trevor Project , supra note 38, at 7 (showing high levels of violence and discrimination against transgender youth).

^ See sources cited supra notes 38–40 and accompanying text.

^ See Goldberg et al., supra note 7, at 7.

^ See Hembree et al., supra note 20, at 3880–81 (listing various “[i]rreversible and . . . undesirable sex characteristics” that develop during assigned-sex puberty, id . at 3881); Turban et al., supra note 41, at 6.

^ See Jenifer K. McGuire et al., Body Image in Transgender Young People: Findings from a Qualitative, Community Based Study , 18 Body Image 96, 103 (2016) (noting that transgender young people feel social stress when they exhibit physical characteristics associated with their assigned sexes); Developments in the Law — Sexual Orientation & Gender Identity , 127 Harv. L. Rev . 1680, 1726 (2014) (noting the “severe negative impact” of discrimination on trans students’ educational outcomes and that socially transitioned trans youth “report a healthier sense of belonging than their peers who are not able to express and embrace their transgender identities”).

^ See, e.g ., Laura Kuper , IMPACT LGBT Health & Dev. Program , Puberty Blocking Medications 8 (2014), <a href=" https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf ">https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf">https://www.impactprogram.org/wp-content/uploads/2014/12/Kuper-2014-Puberty-Blockers-Clinical-Research-Review.pdf [ https://perma.cc/78G8-PAZW ] (“[I]t is more difficult to align the body with one’s affirmed gender once physical changes in [puberty] occur . . . .”). It should be noted, however, that the concept of “passing” as one’s identified gender may not apply to nonbinary individuals, whose gender identities may not align with a binary mode of gender presentation. Cf . Christina Richards, Psychology , in Genderqueer and Non-binary Genders , supra note 7, at 141, 147 (noting that the genders of nonbinary people may be “socially unintelligible” such that they “find themselves in the trap of either seeming to be what they aren’t and so being accepted, or seeming to be what they are and so facing opprobrium”).

^ See Margaret To et al., Visual Conformity with Affirmed Gender or “Passing”: Its Distribution and Association with Depression and Anxiety in a Cohort of Transgender People , 17 J. Sexual Med . 2084, 2088 (2020).

^ See id . at 2089; Brynn Tannehill, For Many Trans People, Not Passing Is Not an Option , Slate (June 27, 2018, 11:54 AM), <a href=" https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html ">https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html">https://slate.com/human-interest/2018/06/not-passing-or-blending-is-dangerous-for-many-trans-people.html [ https://perma.cc/3EPP-6ZNS ].

^ See Costa et al., supra note 41, at 2212 (stating that use of puberty blockers results in “improvement in many aspects of . . . psychosocial functioning, such as mood improvement and school integration”); McGuire et al., supra note 51, at 105 (reporting increased confidence, self-acceptance, and social adjustment in trans youth who transition).

^ See, e.g ., Kuper , supra note 52, at 8; Ikuta, supra note 6, at 213.

^ See To et al., supra note 53, at 2089; Tannehill, supra note 54.

^ See Nat’l Ctr. for Transgender Equal., Summary of State Birth Certificate Gender Change Laws (2020), <a href=" https://transequality.org/sites/default/files/docs/resources/Summary of State Birth Certificate Laws Jan 2020.pdf"><a href="https://transequality.org/sites/default/files/docs/resources/Summary%20of%20State%20Birth%20Certificate%20Laws%20Jan%202020.pdf ">https://transequality.org/sites/default/files/docs/resources/Summary%20of%20State%20Birth%20Certificate%20Laws%20Jan%202020.pdf [ https://perma.cc/PP39-SYZ2 ]; Identity Document Laws and Policies , Movement Advancement Project (Feb. 11, 2021), <a href=" https://www.lgbtmap.org/equality-maps/identity_document_laws ">https://www.lgbtmap.org/equality-maps/identity_document_laws">https://www.lgbtmap.org/equality-maps/identity_document_laws [ https://perma.cc/E2BP-4HB7 ].

^ See Abbie E. Goldberg, Genny Beemyn & JuliAnna Z. Smith, What Is Needed, What Is Valued: Trans Students’ Perspectives on Trans-Inclusive Policies and Practices in Higher Education , 29 J. Educ. & Psych. Consultation 27, 31–32 (2019).

^ Jacob Gershman, States Weigh Measures to Stop Transgender Athletes from Competing in Women’s Sports , Wall St. J . (Jan. 7, 2020, 5:30 AM), <a href=" https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001 ">https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001">https://www.wsj.com/articles/states-weigh-measures-to-stop-transgender-athletes-from-competing-in-womens-sports-11578393001 [ https://perma.cc/SX58-6ERN ]; see NCAA Off. of Inclusion, NCAA Inclusion of Transgender Student-Athletes 13 ( 2011) , <a href=" https://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf ">http://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf">https://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf [ https://perma.cc/RG7X-HHJ2 ]. Along with their campaigns against gender-affirming healthcare, see infra section B.1, pp. 2172–75, state legislatures have launched a parallel nationwide offensive against trans girls’ participation in women’s sports, see Gershman, supra ; see also , e.g ., Hecox v. Little, No. 20-cv-00184, 2020 WL 4760138, at *15, *39 (D. Idaho Aug. 17, 2020) (granting preliminary injunction against one such athletics ban on trans girls).

^ See, e.g ., NCAA Off. of Inclusion , supra note 60, at 13 (“A trans male (FTM) student-athlete who is not taking testosterone related to gender transition may participate on a men’s or women’s team.”).

^ Cf . David J. Handelsman, Angelica L. Hirschberg & Stephanie Bermon, Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance , 39  Endocrine Revs . 803, 823 (2018) (finding that higher testosterone explains “most, if not all, the sex differences in sporting performance”).

^ See The Biden Plan to Advance LGBTQ+ Equality in America and Around the World , Biden for President , <a href=" https://joebiden.com/lgbtq-policy ">https://joebiden.com/lgbtq-policy/">https://joebiden.com/lgbtq-policy [ https://perma.cc/8TDP-C4UD ]; Dear Colleague Letter on Transgender Students from Catherine E. Lhamon, Assistant Sec’y for C.R., U.S. Dep’t of Educ. & Vanita Gupta, Principal Deputy Assistant Att’y Gen. for C.R., U.S. Dep’t of Just. 3 (May 13, 2016), https://www2.ed.gov/about/offices/list/ocr/letters/colleague-201605-title-ix-transgender.pdf [ https://perma.cc/85P9-GFHP ].

^ Cf., e.g ., Adams ex rel . Kasper v. Sch. Bd., 318 F. Supp. 3d 1293, 1326 (M.D. Fla. 2018), aff’d , 968 F.3d 1286 (11th Cir. 2020) (crediting evidence of the plaintiff’s “social, medical, and legal transitions” in determining he had a right to use the boys’ restroom at school).

^ See Teo Armus, A Texas Man Says His 7-Year-Old Isn’t Transgender. Now His Custody Fight Has Reached the Governor’s Office ., Wash. Post (Oct. 24, 2019, 6:13 AM), <a href=" https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott ">https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott/">https://www.washingtonpost.com/nation/2019/10/24/james-younger-luna-transgender-greg-abbott [ https://perma.cc/WSH8-BDJF ].

^ See, e.g ., Senator Ted Cruz (@SenTedCruz), Twitter (Oct. 23, 2019, 7:01 PM), <a lang="en"" href=" https://twitter.com/sentedcruz/status/1187157024888496128 ">https://twitter.com/sentedcruz/status/1187157024888496128?lang=en">https://twitter.com/sentedcruz/status/1187157024888496128 [ https://perma.cc/X67V-3LQZ ] (accusing the mother of “child abuse”).

^ María Méndez, Could Transgender Kids’ Care Be Next “Bathroom Bill” for Texas Republicans? , Dall. Morning News (Oct. 25, 2019, 11:57 AM), <a href=" https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans ">https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans/">https://www.dallasnews.com/news/politics/2019/10/25/could-transgender-kids-care-be-next-bathroom-bill-for-texas-republicans [ https://perma.cc/7MCJ-DWYA ].

^ See About Heritage , Heritage Found ., <a href=" https://www.heritage.org/about-heritage/impact ">https://www.heritage.org/about-heritage/impact">https://www.heritage.org/about-heritage/impact [ https://perma.cc/TPW2-KYPQ ].

^ See, e.g ., Summit on Protecting Children from Sexualization , Heritage Found ., at 2:12:28 (Oct. 9, 2019), <a href=" https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization ">https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization">https://www.heritage.org/marriage-and-family/event/summit-protecting-children-sexualization [ https://perma.cc/DN2P-RRXZ ] [hereinafter Summit ]; see also Brianna January, Anti-LGBTQ Group Heritage Foundation Has Hosted Four Anti-trans Panels So Far in 2019 , Media Matters for Am . (Apr. 18, 2019, 9:18 AM), <a href=" https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far ">https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far">https://www.mediamatters.org/heritage-foundation/anti-lgbtq-group-heritage-foundation-has-hosted-four-anti-trans-panels-so-far [ https://perma.cc/Q7SK-D5DT ].

^ See Sydney Bauer, The New Anti-trans Culture War Hiding in Plain Sight , New Republic (Feb. 11, 2020), <a href=" https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight ">https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight">https://newrepublic.com/article/156539/new-anti-trans-culture-war-hiding-plain-sight [ https://perma.cc/ZC7X-JK3E ]; Chris Johnson, Advocates Prepare for Fight as Anti-trans Youth Legislation Advances in S.D ., Wash. Blade (Jan. 31, 2020, 2:22 PM), <a href=" https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d ">https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d/">https://www.washingtonblade.com/2020/01/31/advocates-prepare-for-fight-as-anti-trans-youth-legislation-advances-in-s-d [ https://perma.cc/85YF-JHX3 ].

^ See Bauer, supra note 71; Summit , supra note 70. Model legislation is often a symptom of pervasive interest group influence in state legislatures. See Rob O’Dell & Nick Penzenstadler, You Elected Them to Write New Laws. They’re Letting Corporations Do It Instead ., USA Today (June 19, 2019, 5:56 PM), <a href=" https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002 ">https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002/">https://www.usatoday.com/in-depth/news/investigations/2019/04/03/abortion-gun-laws-stand-your-ground-model-bills-conservatives-liberal-corporate-influence-lobbyists/3162173002 [ https://perma.cc/3ACT-WP3W ].

^ See sources cited supra note 9. Although a Utah Representative was considering a bill to ban HRT and GCS, he changed course and drafted a bill geared toward exploratory research into gender-affirming healthcare. See Connor Richards, Utah House Rejects Bill to Study Effects of Hormone Therapy on Transgender Minors , Daily Herald (Mar. 10, 2020), https://www.heraldextra.com/news/local/govt-and-politics/legislature/utah-house-rejects-bill-to-study-effects-of-hormone-therapy-on-transgender-minors/article_2fc144a0-9573-50fc-a6e7-60841a6d8632.html [ https://perma.cc/M4CH-44DC ]. The fifteen-state count thus does not include the Utah bill.

^ For a database containing links to the text, sponsors, and status of the 2020 bills, see ACLU Legislation Tracker , supra note 9. For the bills introduced so far in 2021, see sources cited supra note 11; Legislation Affecting LGBT Rights Across the Country , ACLU (Feb. 11, 2021), https://www.aclu.org/legislation-affecting-lgbt-rights-across-country [ https://perma.cc/RD96-UXDP ].

^ Tennessee’s bill banned all gender-affirming care for minors who have not started puberty, but allowed minors who have begun puberty to receive gender-affirming care upon the recommendation of three physicians. See H.B. 2576, 111th Gen. Assemb., Reg. Sess. § 1(b) (Tenn. 2020). In addition, Missouri’s, Oklahoma’s, and South Carolina’s bills did not contain a “medically verifiable” exception, see H.B. 1721, 100th Gen. Assemb., 2d Reg. Sess. (Mo. 2020); S.B. 1819, 57th Leg., 2d Reg. Sess. (Okla. 2020); H.B. 4716, 123d Gen. Assemb, Reg. Sess. (S.C. 2020), and Mississippi’s and South Dakota’s bills did not follow the eighteen-year cutoff, see S.B. 2490, 2020 Leg., Reg. Sess. § 3(b) (Miss. 2020) (defining minors as below age twenty-one); H.B. 1057, 95th Gen. Assemb., Reg. Sess. (S.D. 2020) (defining minors as below age sixteen).

^ See, e.g ., S. File 2213, 88th Gen. Assemb., Reg. Sess. § 1 (3) (Iowa 2020); H.B. 513, 133d Gen. Assemb., Reg. Sess. § 1, sec. 5128.03(C)(1) (Ohio 2020).

^ See H.B. 465, 65th Leg., 2d Reg. Sess. (Idaho 2020). The law would have defined gender-affirming care as “genital mutilation of a child,” which carries a maximum life sentence under the state criminal code. See id .; Idaho Code § 18-1506B(6) (2020).

^ Cf . Annamarie Forestiere, America’s War on Black Trans Women , Harv. C.R.-C.L. L. Rev. Amicus Blog (Sept. 23, 2020), <a href=" https://harvardcrcl.org/americas-war-on-black-trans-women ">https://harvardcrcl.org/americas-war-on-black-trans-women/">https://harvardcrcl.org/americas-war-on-black-trans-women [ https://perma.cc/DRD4-RHXY ] (noting that high poverty and homelessness rates among Black trans women affect their ability to travel); La’Tasha D. Mayes, Black Women Are Dying from a Lack of Access to Reproductive Health Services , TIME (Jan. 19, 2018, 11:53 AM), <a href=" https://time.com/5109797/black-women-dying-reproductive-health ">https://time.com/5109797/black-women-dying-reproductive-health/">https://time.com/5109797/black-women-dying-reproductive-health [ https://perma.cc/LY33-M8JL ] (showing how similar laws restricting reproductive healthcare access disparately affect people of color).

^ See ACLU Legislation Tracker , supra note 9.

^ See Bauer, supra note 71; Nico Lang, Alabama Moves Closer to Transgender Health Care Ban for Minors , NBC News (Mar. 10, 2020, 4:21 PM), <a href=" https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791 ">https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791">https://www.nbcnews.com/feature/nbc-out/alabama-moves-closer-transgender-health-care-ban-minors-n1154791 [ https://perma.cc/3KDX-HYYE ].

^ See Changes to State Legislative Session Dates in Response to the Coronavirus (COVID-19) Pandemic, 2020 , Ballotpedia (Jan. 21, 2021), https://ballotpedia.org/Changes_to_state_legislative_session_dates_in_response_to_the_coronavirus_(COVID-19)_pandemic,_2020 [ https://perma.cc/JK26-WYNM ]; ACLU Legislation Tracker , supra note 9 (showing that several bills died in committee in mid-March).

^ See Joellen Kralik, “ Bathroom Bill” Legislative Tracking , Nat’l Conf. of State Legislatures (Oct. 24, 2019), <a href=" https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx ">https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx">https://www.ncsl.org/research/education/-bathroom-bill-legislative-tracking635951130.aspx [ https://perma.cc/5JH4-QPZA ] (listing the states).

^ See Elena Schneider, The Bathroom Bill that Ate North Carolina , Politico Mag . (Mar. 23, 2017), <a href=" https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944 ">https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944">https://www.politico.com/magazine/story/2017/03/the-bathroom-bill-that-ate-north-carolina-214944 [ https://perma.cc/5E4M-VHQC ]; see also N.C. Gen. Stat . § 143-760(b), (d) (repealed 2017).

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 (Eng.). The court ruled that puberty blockers are presumptively inappropriate for adolescents under sixteen, id . at [151], and that court authorization may be necessary for sixteen- and seventeen-year-olds, id . at [152].

^ See, e.g ., G.B. v. Lackner, 145 Cal. Rptr. 555, 556, 559 (Ct. App. 1978) (reversing state health department’s denial of insurance coverage for GCS).

^ See, e.g ., Whitman-Walker Clinic, Inc. v. U.S. Dep’t of Health & Hum. Servs., No. CV 20-1630, 2020 WL 5232076, at *1 (D.D.C. Sept. 2, 2020) (challenging the Trump Administration’s rescission of an Obama Administration policy banning discrimination against transgender people in healthcare). For an overview of other legal battles surrounding gender-affirming healthcare, see generally Judson Adams et al., Transgender Rights and Issues , 21 Geo. J. Gender & L . 479, 494–507 (2020).

^ S.B. 2490, 2020 Leg., Reg. Sess. § 2(1)(a) (Miss. 2020).

^ See, e.g ., id . § 2(2); H.B. 3515, 101st Gen. Assemb., Reg. Sess. § 10 (Ill. 2019). Indeed, many of the bills even share a version of the same title: “Vulnerable Child Protection Act.” See, e.g ., H.B. 303, 2020 Leg., Reg. Sess. § 1 (Ala. 2020); H.B. 1365, 2020 Leg., Reg. Sess. (Fla. 2020); H.B. 513, 133d Gen. Assemb., Reg. Sess. § 2 (Ohio 2020).

^ See Amy L. Stone, Gender Panics About Transgender Children in Religious Right Discourse , 15 J. LGBT Youth 1, 1–3 (2018).

^ See, e.g ., Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586, 613–14 (4th Cir. 2020); id . at 626 (Wynn, J., concurring); Doe ex rel . Doe v. Boyertown Area Sch. Dist., 897 F.3d 518, 526 (3d Cir. 2018); see also Note, Constitutional Privacy and the Fight Over Access to Sex-Segregated Spaces , 133 Harv. L. Rev . 1684, 1685 (2020).

^ See, e.g ., Grimm , 972 F.3d at 620; Doe , 897 F.3d at 538.

^ See Gabby Orr, The Wedge Issue That’s Dividing Trumpworld , Politico Mag . (Aug. 7, 2020, 7:08 AM), <a href=" https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323# ">https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323">https://www.politico.com/news/magazine/2020/08/07/wedge-issue-dividing-trumpworld-392323# [ https://perma.cc/M2H2-JTBL ] (noting that “public opinion [is] moving dramatically in favor” of transgender rights); Schneider, supra note 83 (detailing the backlash to House Bill 2 in North Carolina).

^ See, e.g ., Orr, supra note 92 (detailing a sharply divided opinion within the Trump reelection campaign concerning whether to embrace an explicitly antitransgender platform).

^ Professor Reva Siegel has termed this phenomenon “preservation-through-transformation.” Reva B. Siegel, “ The Rule of Love”: Wife Beating as Prerogative and Privacy , 105 Yale L.J . 2117, 2180 (1996); see id . at 2179 (“[T]he manner in which a legal system enforces social stratification . . . evolve[s] over time, changing shape as it is contested.”).

^ See Editorial, Lawmakers Reach New Low with Latest Transgender Bill , Argus Leader (Jan. 27, 2020, 10:14 AM), <a href=" https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002 ">https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002/">https://www.argusleader.com/story/opinion/editorials/2020/01/23/south-dakota-legislature-transgender-bill-fred-deutsch/4551350002 [ https://perma.cc/EHA6-QVMU ] (noting that the chief sponsor of the 2020 South Dakota gender-affirming care ban also introduced the state’s failed bathroom bill in 2016); Chase Strangio, Conservative Legislators Want Transgender Kids’ Lives as the New Battlefield in Their Culture War , NBC News (Jan. 17, 2021, 3:30 AM), <a href=" https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483 ">https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483">https://www.nbcnews.com/think/opinion/conservative-legislators-want-transgender-kids-lives-new-battlefield-their-culture-ncna1254483 [ https://perma.cc/8AXG-39EJ ].

^ See Nancy J. Knauer, The Politics of Eradication and the Future of LGBT Rights , 21 Geo. J. Gender & L . 615, 655 (2020); Strangio, supra note 95.

^ See Clifford J. Rosky, Fear of the Queer Child , 61 Buff. L. Rev . 607, 638–39 (2013) (noting that paternalistic justifications for opposing LGBTQ youth are “more appealing to a wide audience and more challenging for LGBT advocates to rebut,” id . at 639).

^ See Strangio, supra note 95; see also Knauer, supra note 96, at 637 (“By focusing on the element of choice and the ability to change, anti-LGBT advocates . . . attempt to not only destabilize LGBT identities, but to eradicate them completely because they believe that being LGBT is not a choice that anyone should make.”).

^ See Bell v. Tavistock [2020] EWHC (Admin) 3274 (Eng.). Immediately after the High Court upheld a challenge to the National Health Service (NHS) gender-affirming treatment protocol for minors, framing the decision as an exercise of “the protective role of the court,” id . at [149], the defendant NHS trust announced a moratorium on new referrals for puberty blockers, see Owen Bowcott, Puberty Blockers: Under-16s “Unlikely to Be Able to Give Informed Consent ,” The Guardian (Dec. 1, 2020, 12:18 AM), <a href=" https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules ">https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules">https://www.theguardian.com/world/2020/dec/01/children-who-want-puberty-blockers-must-understand-effects-high-court-rules [ https://perma.cc/L4CR-4KJ7 ].

^ See supra p. 2175.

^ See Rafferty, supra note 5, at 4 (“[C]hildren who are prepubertal and assert [a trans identity] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender . . . .”); see also Anne A. Fast & Kristina R. Olson, Gender Development in Transgender Preschool Children , 89 Child Dev . 620, 631–32 (2018) (finding that “[a]cross all measures of preference, behavior, stereotyping, and identity . . . preschool-age socially transitioned transgender children never significantly differed from their [cisgender] peers,” id . at 631).

^ See Jesse Singal, When Children Say They’re Trans , The Atlantic (July/Aug. 2018), <a href=" https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749 ">https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749/">https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749 [ https://perma.cc/P7RZ-CH57 ].

^ See Julia Temple Newhook et al., A Critical Commentary on Follow-Up Studies and “Desistance” Theories About Transgender and Gender-Nonconforming Children , 19 Int’l J. Transgenderism 212, 212–13 (2018) (claiming that the studies showing “desistance” of gender dysphoria are methodologically flawed).

^ See id . at 218 (noting that “desistance” arguments concerning gender nonconforming youth “reinforce [a] limited binary perspective on gender and sexuality” and that “if we find that people do not fit our categories, then it is the categories that must change”); see also Goldberg et al., supra note 7, at 92.

^ See WPATH SOC , supra note 17, at 14, 18–19.

^ See Singal, supra note 102; see also WPATH SOC, supra note 17, at 18 (“Before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken . . . .”).

^ U.S. Const . amend . XIV , § 1.

^ See City of Cleburne v. Cleburne Living Ctr., Inc., 473 U.S. 432, 439–40 (1985).

^ See, e.g ., Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586, 607 (4th Cir. 2020).

^ See, e.g ., Cleburne , 473 U.S. at 440–42; Grimm , 972 F.3d at 608; see also Ashutosh Bhagwat, Purpose Scrutiny in Constitutional Analysis , 85 Calif. L. Rev . 297, 303–04 (1997).

^ See, e.g ., Grimm , 972 F.3d at 607; Adams ex rel . Kasper v. Sch. Bd., 968 F.3d 1286, 1296, 1304 (11th Cir. 2020); Whitaker ex rel . Whitaker v. Kenosha Unified Sch. Dist. No. 1 Bd. of Educ., 858 F.3d 1034, 1051–52 (7th Cir. 2017).

^ See, e.g ., Grimm , 972 F.3d at 610; Karnoski v. Trump, 926 F.3d 1180, 1201 (9th Cir. 2019); see also Kevin M. Barry et al., A Bare Desire to Harm: Transgender People and the Equal Protection Clause , 57 B.C. L. Rev . 507, 551–67 (2016) (arguing that transgender status satisfies the four-factor test for whether a group should receive protected status).

^ See, e.g ., Whitaker , 858 F.3d at 1051; Glenn v. Brumby, 663 F.3d 1312, 1317 (11th Cir. 2011); Smith v. City of Salem, 378 F.3d 566, 568, 577 (6th Cir. 2004).

^ H.B. 321, 2020 Gen. Assemb., Reg. Sess. § 1(3) (Ky. 2020); see, e.g ., id . § 1(2); H.B. 303, 2020 Leg., Reg. Sess. § 4 (Ala. 2020). Even the bills that do not specifically except treatment of intersex or developmental conditions from the prohibitions imply through their language that the bans only apply to use of the prohibited services as gender-affirming medical treatment. See, e.g ., H.B. 2210, 100th Gen. Assemb., 2d Reg. Sess. § A(1) (Mo. 2020) (prohibiting medical providers from “administering any hormonal treatment or performing any surgical treatment for the purpose of gender reassignment ” (emphasis added)); see also S.B. 1819, 57th Leg., 2d Reg. Sess. § 1(C) (Okla. 2020).

^ See, e.g ., Christian Legal Soc’y Chapter of the Univ. of Cal., Hastings Coll. of the Law v. Martinez, 561 U.S. 661, 689 (2010) (“A tax on wearing yarmulkes is a tax on Jews.” (quoting Bray v. Alexandria Women’s Health Clinic, 506 U.S. 263, 270 (1993))).

^ 140 S. Ct. 1731 (2020).

^ See id . at 1754.

^ Id . at 1747.

^ See id . at 1783 (Alito, J., dissenting) (“By equating discrimination because of sexual orientation or gender identity with discrimination because of sex, the Court’s decision will be cited as a ground for subjecting all three forms of discrimination to [heightened scrutiny].”); see also, e.g ., Adams ex rel . Kasper v. Sch. Bd., 968 F.3d 1286, 1296 (11th Cir. 2020) (applying Bostock to find that a school board policy discriminating against transgender students was sex discrimination warranting heightened scrutiny).

^ Bostock , 140 S. Ct. at 1741.

^ See Flack v. Wis. Dep’t of Health Servs., 328 F. Supp. 3d 931, 948 (W.D. Wis. 2018) (observing that a Medicaid exclusion for gender-affirming healthcare was “a straightforward case of sex discrimination” because “if plaintiffs’ natally assigned sexes had matched their gender identities, their requested, medically necessary surgeries to reconstruct their genitalia or breasts would be covered”).

^ United States v. Virginia, 518 U.S. 515, 524 (1996) (citations omitted); see Bhagwat, supra note 110, at 304. While this test for “intermediate scrutiny” has been used for gender-based classifications, courts apply a more searching “strict scrutiny” test for certain other classifications. See id .

^ See supra section A.2, pp. 2167–72.

^ See supra section B.2, pp. 2175–78.

^ See sources cited supra note 19.

^ See, e.g ., What We Know Project , supra note 42 (stating that, of more than fifty studies published between 1991 and 2017, ninety-three percent “found that gender transition improves the overall well-being of transgender people,” and that there were “no studies concluding that gender transition causes overall harm”) ; see also sources cited supra notes 41–42. But see infra pp. 2184–85 (describing concerns with judicial analysis of scientific evidence).

^ See Bhagwat, supra note 110, at 303 (discussing rational basis review).

^ H.B. 303, 2020 Leg., Reg. Sess. § 2(1) (Ala. 2020).

^ Id . § 4(b). The Alabama bill defines “medically verifiable” conditions to include “external biological sex characteristics that are irresolvably ambiguous . . . , [such as] having both ovarian and testicular tissue,” and “[ab]normal sex chromosome structure, sex steroid hormone production, or sex steroid hormone action.” Id .

^ See, e.g ., Romer v. Evans, 517 U.S. 620, 634 (1996) (explaining that “a bare . . . desire to harm a politically unpopular group cannot constitute a legitimate government interest” (citation omitted)); City of Cleburne v. Cleburne Living Ctr., Inc., 473 U.S. 432, 446–47 (1985); Susannah W. Pollvogt, Unconstitutional Animus , 81 Fordham L. Rev . 887, 888 (2012).

^ See Pollvogt, supra note 132, at 926–27.

^ 473 U.S. 432.

^ See id . at 447–50. In Cleburne , the Court held that a city’s denial of a special zoning permit to a group home for people with intellectual disabilities violated equal protection because it was founded on “irrational prejudice” against such people. Id . at 450. The Court inferred prejudice in part because the city imposed special permitting requirements on the group home for reasons such as density, traffic congestion, and exposure to litigation risk that applied equally to other high-density residential uses, such as nursing homes and dormitories, for which special permits were not required. See id . at 447–50.

^ Cf . Romer , 517 U.S. at 635; Cleburne , 473 U.S. at 450.

^ See Jessica A. Clarke, Explicit Bias , 113 Nw. U. L. Rev . 505, 511 (2018) (defending the probative value of explicit statements of bias as evidence of discriminatory intent); Pollvogt, supra note 132, at 927.

^ Jeff Taylor, Florida Lawmaker Told Nonbinary Candidate He’s “Manufacturing” His Identity , NewNowNext (Feb. 4, 2020), <a href=" https://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020 ">http://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020/">https://www.newnownext.com/florida-republican-sabatini-gender-nonbinary-manufacturing-identity/02/2020 [ https://perma.cc/3NTT-LSBB ].

^ Katie Shepherd, A GOP Lawmaker, the Son of an Auschwitz Survivor, Compared Doctors Treating Transgender Children to Nazis. He Regrets It ., Wash. Post (Jan. 28, 2020, 11:45 AM), <a href=" https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi ">https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi/">https://www.washingtonpost.com/nation/2020/01/28/deutsch-transgender-doctors-nazi [ https://perma.cc/7AJH-AMJX ]. To his credit, Rep. Deutsch later apologized. Id .

^ John Herrick, Anti-LGBTQ Bills Doomed to Die. Advocates Say They Still Take a Toll ., Colo. Indep . (Feb. 13, 2020), <a href=" https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth ">https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth/">https://www.coloradoindependent.com/2020/02/13/gop-anti-lgbtq-transgender-youth [ https://perma.cc/GQP4-8AJP ].

^ See Emily Jashinsky, Exclusive: Man Tried to Share His Regrets About Transgender Life. YouTube Censored It , Federalist (June 19, 2020), https://thefederalist.com/2020/06/19/exclusive-man-tried-to-share-his-regrets-about-transgender-life-youtube-censored-it [ https://perma.cc/9JEM-M7NJ ]; see also, e.g ., Summit , supra note 70, at 2:15:20 (panelist describing the pioneers of gender-affirming treatment for minors as “pedophile activist[s]”).

^ Transgenderism & Gender Dysphoria , Fam. Pol’y All . (internal quotation marks omitted), <a href=" https://familypolicyalliance.com/issues/sexuality/transgender ">https://familypolicyalliance.com/issues/sexuality/transgender/">https://familypolicyalliance.com/issues/sexuality/transgender [ https://perma.cc/77QD-7FMA ]; see Bauer, supra note 71.

^ See Pierce v. Soc’y of Sisters, 268 U.S. 510, 534–35 (1925); Meyer v. Nebraska, 262 U.S. 390, 399 (1923).

^ See, e.g ., Troxel v. Granville, 530 U.S. 57, 65–66 (2000); Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 851 (1992); Moore v. City of East Cleveland, 431 U.S. 494, 499 (1977); Stanley v. Illinois, 405 U.S. 645, 651 (1972).

^ Troxel , 530 U.S. at 65.

^ See id . at 69–70.

^ See Parham v. J.R., 442 U.S. 584, 603–04 (1979) (recognizing “parents’ authority to decide what is best for the[ir] child” in the medical context, id . at 604); see also Kanuszewski v. Mich. Dep’t of Health & Hum. Servs., 927 F.3d 396, 418–19 (6th Cir. 2019).

^ See, e.g ., Kanuszewski , 927 F.3d at 418–19; PJ ex rel . Jensen v. Wagner, 603 F.3d 1182, 1197 (10th Cir. 2010); Restatement of the Law, Children and the Law § 2.30 (Am. L. Inst ., Tentative Draft No. 1, 2018) ; Alicia Ouellette, Shaping Parental Authority over Children’s Bodies , 85 Ind. L.J . 955, 966–68 (2010).

^ See Prince v. Massachusetts, 321 U.S. 158, 166–67 (1944).

^ See, e.g ., Cal. Bus. & Prof. Code § 865.1 (West 2021); Editorial, A Nationwide Ban Is Needed for “Anti-gay Therapy ,” Sci. Am . (Jan. 1, 2020), <a href=" https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy ">https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy/">https://www.scientificamerican.com/article/a-nationwide-ban-is-needed-for-anti-gay-therapy [ https://perma.cc/BV37-ZYVH ].

^ Pickup v. Brown, 740 F.3d 1208, 1236 (9th Cir. 2014); see also, e.g ., Doe ex rel . Doe v. Governor of N.J., 783 F.3d 150, 156 (3d Cir. 2015) (same).

^ See Doe , 783 F.3d at 152–53; Pickup , 740 F.3d at 1231–32.

^ Compare, e.g ., Policy Statement, Conversion Therapy , Am. Acad. Child & Adolescent Psychiatry (2018), <a href=" https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx ">https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx">https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx [ https://perma.cc/LV4U-SV3P ] (confirming that conversion therapy “lack[s] scientific credibility and clinical utility”), and Editorial, supra note 150 (noting that various medical associations characterize conversion therapy as “useless and injurious”), with, e.g ., AACAP Statement , supra note 46 (stating that “AACAP strongly opposes any efforts . . . to block access” to “evidence-based [gender-affirming] care”), and Endocrine Soc’y & Pediatric Endocrine Soc’y, supra note 46, at 2 (describing gender-affirming care for minors as “effective, relatively safe when appropriately monitored, and . . . the standard of care” (parentheses omitted)).

^ See Joseph Landau, Broken Records: Reconceptualizing Rational Basis Review to Address “Alternative Facts” in the Legislative Process , 73 Vand. L. Rev . 425, 443–44 (2020) (noting that the doctrinal framework for judicial review of legislative purposes is ill-equipped to protect marginalized groups from “distorted legislative records” based on “alternative facts,” id . at 443).

^ See, e.g ., Gonzales v. Carhart, 550 U.S. 124, 179–82 (2007) (Ginsburg, J., dissenting) (describing the majority’s “bewildering,” id . at 179, rejection of the “significant medical authority,” id . at 180 (quoting Stenberg v. Carhart, 530 U.S. 914, 932 (2000)), supporting the use of a late-term abortion procedure to protect the patient’s health in some circumstances); id . at 182 (“Ultimately, the Court admits that moral concerns are at work . . . .” (quotation marks omitted)).

^ See, e.g ., Gibson v. Collier, 920 F.3d 212, 223 (5th Cir. 2019) (“There is no medical consensus that sex reassignment surgery is a necessary or even effective treatment for gender dysphoria.”).

^ See, e.g ., Edmo v. Corizon, Inc., 935 F.3d 757, 803 (9th Cir. 2019) (holding that prison officials’ denial of medically necessary gender-affirming medical care violated the Eighth Amendment).

^ Palmore v. Sidoti, 466 U.S. 429, 433 (1984).

^ WPATH SOC, supra note 17, at 21.

^ See Ikuta, supra note 6, at 227–28.

• Health Care Law
• LGBT Rights

April 12, 2021

More from this Issue

Reframing the harm: religious exemptions and third-party harm after little sisters.

Chapter Two

The Legal Infrastructure of Childbirth

Chapter Three

Conditions of Confinement, COVID-19, and the CDC

Chapter Four

What to Know About the Gender-Affirming-Care Bans Spreading Across the Country

O nly six states in the U.S. have not introduced a bill restricting LGBTQ rights during this legislative session, including Delaware and Illinois. Bathroom bills, measures that would limit the ability to update identity and gender information on records and IDs, sports bans, and bans on gender-affirming care are all up for consideration in states across America.

That last category of bills is growing. On Thursday, Iowa prohibited gender-reassignment procedures and prescriptions, and two of Florida’s State Senate committees passed Senate Bill 254, which would add onto the existing gender-affirming-care restrictions by prohibiting entities from using state funds to cover gender-affirming care, among other things.

Just this year, five states—Mississippi, Utah, South Dakota, Iowa, and Tennessee—have passed bans on gender-affirming care for minors, and nearly 90 other bills targeting access to gender-affirming health care, including Florida’s, are being considered in the U.S.

Proponents of these measures often claim these laws will protect young Americans from what they portray as risky medical experimentation. “We need to let kids be kids, and our laws need to set appropriate boundaries that respect the rights and responsibilities of parents, while protecting children from the serious health, safety, and welfare consequences of social agendas that are totally inconsistent with how the overwhelming majority of parents want to raise their children,” says Florida State Sen. Yarborough, the sponsor of a gender-affirming-care ban in the state, in a press release.

But every major medical organization—including the American Medical Association, American Academy of Pediatrics, American Psychiatric Association, and more— agrees that gender-affirming care for transgender patients , which can range from social interventions, to hormonal treatments, to surgery, is both safe and medically appropriate. For transgender people, who face unemployment at twice the rate of the general population and have a suicide rate nearly nine times that of the broader U.S. population, the prospect of losing access to such care is harrowing.

“Many adolescents with gender dysphoria have severe negative psychological reactions to their bodies developing in ways that do not align with who they are, and [hormonal treatments] can temporarily put these changes on pause,” Dr. Jack Turban, Assistant Professor of Child & Adolescent Psychiatry at The University of California, San Francisco, tells TIME.

Here’s what to know about some of the gender-affirming-care bans being considered across the U.S.

Where have bans been passed already?

Eight states already have gender-affirming-care bans in place for people under the age of 18, and states like Tennessee and Iowa, which both passed legislation this year, are part of the rise in anti-trans legislation being considered more broadly.

They join states like Arkansas, which passed similar legislation two years ago. (Ongoing lawsuits in Arkansas have delayed the program from rolling out, though legislators passed a measure that would criminalize medical practitioners for providing gender- affirming care for minors in March 2023.) Arizona and Alabama also passed gender-care bans in 2022, though the latter’s law is temporarily blocked by legal challenges.

Most laws in this category, like that of Tennessee, would ban puberty blockers and hormone treatment from being used to treat gender dysphoria. Patients would also be unable to undergo surgery.

Healthcare providers who violate the Tennessee law can be sued in civil court within 30 years of the violation. They could also face a fine of up to $25,000 and have their license restricted.

The Tennessee law, which could face lawsuits, is set to go into effect in the summer, though minors who are currently undergoing treatment have until March 31, 2024 to stop treatment.

Where are gender-affirming-care bans being considered?

While the many restrictions on gender-affirming care being considered in state houses across the country do share some similarities, state lawmakers are trying a range of tactics to control access to such medical treatment.

In Oklahoma, for example, state senators are advancing Senate Bill 613 , which would revoke doctors’, nurse practitioners’, or advanced practice nurses’ licenses if they offer gender-transition services to people under the age of 18. (Legislators did add a measure that says the bill would not prevent mental health counseling, depression and anxiety medication or “medications prescribed, dispensed, or administered specifically for the purpose of treating precocious puberty or delayed puberty in that patient.”)

Another bill being considered in the state, Senate Bill 129, adds onto the restrictions by banning transgender medical care at hospitals that indirectly receive public funding. This includes hospitals that are on land that is owned by a state or local government, according to the Oklahoman . House Bill 2177, meanwhile, would prohibit insurance from covering some gender-affirming care, including puberty blockers for minors, is also being considered.

“[People said] we need to protect sports…and then [legislators] didn’t and we knew it wasn’t going to stop there,” Eddie Hefner, a 22-year-old trans, nonbinary Oklahoma resident says. “That’s not what this is about. This is trans-affirming care across the board. And trans health care is essential for saving [lives] because, [for] a lot of the people that I know, to them it is just normal health care.”

Hefner, who plans on getting one gender-affirming surgery in the future, fears that legislators will make age restrictions increasingly strict—and, they say, 18 is already too late for some care. Under previous medical guidelines, UC San Francisco’s Turban tells TIME, most doctors did not allow patients to use gender-affirming hormones until age 16. (Doctors and mental health providers now work with parents to assess the best time frame for a patient to start estrogen or testosterone, which in some cases may be before 16.) But puberty blockers, which stop processes like voice changes or breast growth, are often used in the earlier stages of puberty.“Forcing [patients] to undergo a puberty that doesn’t align with who they are,” he says, “can be horrifying and traumatic.”

In Florida, a ban took effect on March 16 after the Florida Board of Medicine voted in favor of banning gender-affirming care including puberty blockers, cross-sex hormones, and surgery for minors in November.

Doctors who violate the law could face fines and the potential to have their licenses revoked. Legislators are attempting to make that ban law through Senate Bill 254, which would also mean that any healthcare paid for by the state, like Medicaid or state-employee plans, would not cover gender-affirming care.

Devon Ojeda, the Senior National Organizer at the National Center for Transgender Equality, notes that despite the rhetoric used to attack this form of healthcare, cisgender people could also be affected by these types of bans. “Cancer survivors who get breast implants, regardless if they’re cisgender or not, [are getting surgeries that are] affirming their gender,” Ojeda says. “Gender affirming care is for everyone.”

The bill would also allow Florida courts “to enter, modify, or stay a child custody determination relating to a child present in this state to the extent necessary to protect the child from being subjected to sex-reassignment prescriptions or procedures in another state.”

Two Senate committees have passed the bill. It will now head to the Senate floor for a vote.

In Missouri, the State Senate voted to advance their gender-affirming ban after a series of back-door negotiations in which Republican lawmakers agreed they would not prohibit people who are already transitioning from doing so, according to the Associated Press . (Florida’s medical rule has a similar provision.) Missouri’s Attorney General Andrew Bailey also announced on Monday that he would pass an emergency rule that would limit gender-affirming care for minors.

Bailey’s plan would require minors endure 15 hour-long therapy sessions and get a full psychiatric evaluation over the course of 18 months before accessing gender-affirming care.

“I am dedicated to using every legal tool at my disposal to stand in the gap and protect children from being subject to inhumane science experiments,” Bailey tweeted .

Organizations like the ACLU, however, contend that these bills will not protect kids, but are instead “harmful and exploitative.”

“There’s nothing extraordinary about this care except that it saves lives,” Harper Seldin, Staff Attorney for the ACLU’s LGBTQ and HIV Project, tells TIME. “I think it’s important to realize that this is not just an attack on this small group of people but is in fact, part of an ongoing attack on the bodily autonomy of people in every state.”

Correction, April 3

The original version of this story misstated when patients may start gender-affirming hormones. Previous medical guidelines instructed doctors not to begin these treatments before patients turned 16, but those guidelines have been updated.

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California governor signs bill offering legal refuge to transgender youths 

California Gov. Gavin Newsom signed a bill Thursday that aims to legally protect transgender youths and their parents if they flee conservative states that have restricted access to gender-affirming care. 

The bill seeks to “offer refuge” to trans minors and their families “if they’re being criminalized in their home states,” state Sen. Scott Wiener, who introduced the bill, said on Twitter after Newsom signed it.

Wiener said states like Texas and Alabama “are seeking to tear these families apart,” referring to efforts in both states to bar parents from providing their trans children with medical care like puberty blockers and hormone therapy.

In February, Texas Gov. Greg Abbott called on the state’s Department of Family and Protective Services to “conduct a prompt and thorough investigation” of any reported instances of minors undergoing “elective procedures for gender transitioning.” He also encouraged anyone who works with children in the state and regular citizens to report parents providing such care. 

Following the directive, the department confirmed that it opened at least nine investigations , but state courts have since blocked most of those investigations .

In Alabama, Gov. Kay Ivey signed a bill that makes it a felony for medical professionals to provide gender-affirming medical care to people under 19. 

“We should especially protect our children from these radical, life-altering drugs and surgeries when they are at such a vulnerable stage in life,” Ivey said in a statement at the time.

A judge partially blocked enforcement of that law in May.

Tennessee also passed a law prohibiting gender-affirming care for prepubertal youth , though advocates said at the time that there were no doctors in the state who provided transition care to children prior to puberty.

As a result of the policies, some families of transgender minors have decided to leave their home states so they can continue to access gender-affirming care, which is supported by accredited medical groups — including the American Medical Association , American Academy of Pediatrics and American Psychological Association .

The bill Newsom signed is intended to protect families and children like those from prosecution in their home states if they travel to California for gender-affirming care or if they move to California after already receiving transition-related care elsewhere. 

“We believe that no one should be prosecuted or persecuted for getting the care they need — including gender-affirming care,” Newsom said in a statement after signing the measure. “With the signing of this bill, California will ensure that these kids and their families can seek and obtain the medical and mental health care that they need.”

The legislation includes a variety of provisions that are meant to help protect families and trans kids. It prohibits California health care providers from releasing medical information in relation to other states’ laws prohibiting gender-affirming care for minors. It also prohibits the enforcement of a court order “based on another state’s law authorizing a child to be removed from their parent or guardian based on that parent or guardian allowing their child to receive gender-affirming health care or gender-affirming mental health care.”

The bill also authorizes a California court to take temporary emergency jurisdiction when a child hasn’t been able to receive gender-affirming health care elsewhere, which some on social media interpreted to mean that California courts will be able to take custody of children if they flee their home states because their parents don’t want to provide them with gender-affirming care. 

But that isn’t accurate, according to Asaf Orr, a senior staff attorney and Transgender Youth Project director at the National Center for Lesbian Rights. Orr said that portion of the bill is related to a court’s jurisdiction in custody matters. 

“State courts around the country have the authority to consider whether to retain jurisdiction over a custody matter involving a child who recently came into the state,” Orr told Reuters . “This typically occurs in instances of domestic violence or other crisis situations. This law simply clarifies that courts should retain jurisdiction in situations where a parent brings their child to California so that they can obtain medical treatment for gender dysphoria.” Gender dysphoria is a medical condition that involves a conflict between an individual’s sex assigned at birth and their gender identity. 

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Jo Yurcaba is a reporter for NBC Out.

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New California law on transgender youths doesn’t remove a parent’s custody

If your time is short.

• A new California law provides legal protections for parents fleeing states that have banned gender-affirming health care for youths.  
• The law clarifies that California courts have jurisdiction over any custody cases that may arise from parents taking their children to the state for care.   
• It doesn’t give the state permission to take custody of a child if one parent disagrees with a child’s decision to seek gender-affirming health care. ​

California Gov. Gavin Newsom recently signed into law a measure that aims to strengthen protections for transgender youths and their families.

Senate Bill 107 contains an array of safeguards for families who arrive in California from states where their children have been denied gender-affirming health care.

It bans courts from enforcing subpoenas from other states regarding minors seeking that care. It prohibits health care providers from releasing medical information. And it clarifies that California courts have jurisdiction over any child custody cases arising from parents taking their children to the state for care.

But a Sept. 29 Facebook post went further to suggest the law says something else: 

"Gov. Gavin Newsom signed Senate Bill 107 into law. In the state of California, your child can now be taken from your custody if you do not affirm gender-reassignment surgery."

The post, shared by the American Council, is a screenshot of a tweet by the group’s founder, Tanner DiBella. The American Council describes itself as an organization dedicated to increasing voter turnout among Christian evangelicals . 

The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed. (Read more about our partnership with Facebook .)

DiBella told PolitiFact the California Legislative Counsel’s summary of the law backs up his reasoning. He pointed specifically to a passage of the summary at the top of bill’s text that reads, "The bill would authorize a court to take temporary jurisdiction because a child has been unable to obtain gender-affirming health care."

But experts we spoke to said that doesn’t mean the state would take custody of the child — it clarifies that California courts would assume jurisdiction of the legal matter. Current law allows California courts to decline jurisdiction in multistate custody matters in certain circumstances.

Courtney Joslin, a Martin Luther King Jr. professor of law at the University of California, Davis School of Law, said the law has nothing to do with who gets custody of a child during a dispute and makes no mention of allowing the court to take custody.

"It’s just describing which courts have jurisdiction in those multi-state (custody disputes)," she said. "There’s no possibility that this bill could be interpreted to do what this person is claiming."

Asaf Orr, a senior staff attorney and Transgender Youth Project director at the National Center for Lesbian Rights, said the bill doesn’t give California carte blanche to remove a child from a parent’s custody. 

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If parents disagree over whether their child should receive gender-affirming care in California, a state court would hear that case and rule based on evidence provided by both parents, Orr said. Out-of-state laws would not apply to the court’s determination. 

Orr said this isn't a new thing, as a state already has jurisdiction over court cases related to children who recently entered that state, for reasons such as escaping from domestic violence. 

"It just ensures that, in situations like this, the court recognizes they have jurisdiction to hear these cases and that they’re going to decide them based on the evidence," he said. "Both parties, as in any court case, will have the opportunity to present evidence and it’s going to be individualized for that young person."

Wendy Seiden, a visiting professor at Chapman University’s Fowler School of Law, said there is nothing in the law that would allow California to take custody of a child. But it does allow California to resist another state’s attempt to remove a parent’s custody if the proposed removal is based on that parent’s efforts to get gender-affirming care for their child.

California state Sen. Scott Wiener, D-San Francisco, an attorney and Senate Bill 170’s author, described DiBella’s interpretation of the text as "categorically false."

"It doesn’t change custody laws in any way," Wiener said. "It just means that, rather than having to go back to Texas or Alabama, they can do it in court here." 

Weiner said he authored the bill in response to proposed legislation in other states involving transgender youth. It provides guidance, he said, for California courts concerning custody hearings involving transgender youths and it helps protect parents who decide to bring their children to the state.

"This bill literally protects parents’ ability to make decisions about children's health care without having to be thrown in prison," Wiener said.

At least 24 states have proposed bills since Jan. 1 targeting transgender or nonbinary youths’ ability to receive gender-affirming care.  

In Texas, Republican Gov. Greg Abbott issued a directive earlier this year that ordered state officials to launch child abuse investigations of parents suspected of allowing their child to receive gender-affirming care. 

Alabama Gov. Kay Ivey signed a law in April that makes providing gender-affirming care for youths a felony, punishable by up to 10 years in prison.

A Facebook post claims that a recently signed California law dealing with gender-affirming care for transgender youth will allow that state to take custody of a child from a parent. 

Experts said that’s not so. The bill clarifies that California courts have jurisdiction to hear any custody cases related to a child being taken to the state to seek gender-affirming health care. It does not say that the courts can take custody of a child. 

We rate this claim False.  

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Facebook post ( archive ), Sept. 29, 2022

Twitter post ( archive ), Sept. 29, 2022

Office of California Gov. Gavin Newsom, SB 107 Signing , Sept. 29, 2022

California Legislature, Senate Bill No. 107 , Oct. 3, 2022

The American Council, About , accessed Oct. 3, 2022

Email with Tanner DiBella, Oct. 3, 2022

Phone interview with Courtney Joslin, Oct. 10, 2022

Phone interview with Asaf Orr, Oct. 3, 2022

Email with Wendy Seiden, Oct. 8, 2022

Phone interview with California State Sen. Scott Wiener, Oct. 3, 2022

The Los Angeles Times, "Newsom signs bill protecting transgender youths and families fleeing red-state policies," Sept. 29, 2022

Bloomberg Law, "Transgender Health Care Becomes Target for Wide GOP-Led Rollback," Sept. 20, 2022

The Texas Tribune, "Transgender Texas kids are terrified after governor orders that parents be investigated for child abuse," Feb. 28, 2022

NBC News, "Alabama ban on gender-affirming care for transgender youth takes effect," May 9, 2022

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Arizona Legislature passes 2 bills to curb transgender rights

The Associated Press

The Arizona House of Representatives gathers during a legislative session on April 6, 2011, in Phoenix. Matt York/AP hide caption

The Arizona House of Representatives gathers during a legislative session on April 6, 2011, in Phoenix.

PHOENIX — The Arizona Legislature passed bills Thursday to prohibit gender reassignment surgery for minors and ban transgender athletes from playing on girls sports teams, joining a growing list of Republican-controlled states attempting to restrict transgender rights as they gain more visibility in culture and society.

Republican Gov. Doug Ducey has not said whether he will sign either bill. Two GOP governors this week bucked conservatives in their party and vetoed bills in Indiana and Utah requiring trans girls to play on boys sports teams.

Texas governor calls gender affirming care 'child abuse.' This family fights back

Republicans have said blocking transgender players from girls sports teams would protect the integrity of women's sports, fearing that trans athletes would have an advantage.

Many point to the transgender collegiate swimmer Lia Thomas, who won an individual title at the NCAA Women's Division I Swimming and Diving Championship last week.

But there are few trans athletes in Arizona schools. Since 2017, about 16 trans athletes have received waivers to play on teams that align with their gender identities out of about 170,000 school-based athletes in the state, according to the Arizona Interscholastic Association.

Efforts to restrict rights for LGBTQ youth

Governors in indiana and utah veto transgender sports bans.

"This bill to me is all about biology," said Republican Rep. Shawnna Bolick, who said she played on a coed team in the 1980s but could not have made the high school boys team. "In my opinion, its unfair to allow biological males to compete with biological girls sports."

Critics said the legislation dehumanizes trans youth to address an issue that hasn't been a problem.

"We're talking about legislating bullying against children who are already struggling just to get by," said Democratic Rep. Kelli Butler. fighting back tears.

Until two years ago, no state had passed a law regulating gender-designated youth sports. But the issue has become front-and-center in Republican-led statehouses since Idaho lawmakers passed the nation's first sports participation law in 2020. It's now blocked in court, along with another in West Virginia.

"This bill is creating a pointless and harmful solution to a non-existent issue," Skyler Morrison, a 13-year-old transgender girl, told lawmakers during a committee hearing earlier this month. "It's obvious this bill is just an excuse to discriminate against transgender girls."

A third of trans youth are at risk of losing gender-affirming care, study says

Republicans around the country have leaned into culture war issues including transgender rights. The debate and vote on the transgender sports legislation came the same morning the House considered and passed a ban on abortions after 15-week gestation . Republicans said little during debates on all three bills.

Arizona is one of 20 states that have considered legislation to restrict gender-affirming health care. The bill originally would have banned all such care for minors but was scaled back to restrict only irreversible procedures, such as surgeries related to gender reassignment.

Similar legislation passed the Idaho House earlier this month but it died in the Senate amid concerns from some Republicans about restricting parental rights.

Supporters of the Arizona bill said it would prevent children from making permanent decisions that they might later come to regret. Republican Rep. John Kavanagh compared the vote to the Legislature's unanimous decision in years past to ban genital mutilation.

"We should stand the same way today because this is mutilation of children," Kavanagh said. "It is irreversible. It is horrific."

Can states limit abortion and gender-affirming treatments outside their borders?

Critics said the decision should be left to parents, their children and the health care team caring for them. They said surgeries are only performed after extensive care and therapy.

"We're talking about our kids, who are already going to be taking the proper steps with their parents to be able to be who they are," said Democratic Rep. Andres Cano.

The bill originally would have banned all gender-affirming care, including hormone therapies and puberty blockers but was scaled back in the Senate.

Similar legislation passed the Idaho House earlier this month but died in the Senate, where some Republicans said they were concerned about restricting parental rights.

• transgender rights

North Carolina Restricts Gender-Affirming Care After Overriding Governor’s Veto—Here Are All The States With Similar Bans Or Restrictions

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The Republican-led North Carolina legislature voted late Wednesday to override a veto from Democratic Gov. Roy Cooper on a bill restricting access to gender-affirming care for minors, joining a growing list of states—including more than a dozen this year—with legislation targeting transgender healthcare.

Most states have issued restrictions this year.

August 16, 2023 The North Carolina legislature approved—after overriding a veto from Gov. Roy Cooper (D)—a bill that prohibits in-state healthcare providers from providing hormone therapy, puberty blockers and gender-reassignment surgeries to anyone under 18, with exceptions for anyone with a “medically verifiable disorder of sex development.”

July 18, 2023 The Republican-led Louisiana legislature approved—after overriding Democratic Gov. John Edwards’ veto—a bill that prohibits in-state healthcare providers from providing gender-reassignment surgeries, puberty blockers and hormone therapy for anyone under 18, though it allows anyone who received gender-affirming care before January 1, 2024, to continue receiving care through the end of next year.

June 7, 2023 Missouri Gov. Mike Parson (R)—who threatened to call a special session to pass a ban—approved a bill that prohibits in-state physicians from performing gender-reassignment surgeries or from prescribing puberty blockers to minors unless they were already receiving treatment before August 28, with an added provision that restricts access to surgeries for imprisoned adults.

June 2, 2023 A new Texas law —which takes effect in September following Gov. Greg Abbott’s signature—prohibits physicians from providing surgery “for the purpose of transitioning a child’s biological sex” or surgery that “sterilizes the child,” and from prescribing puberty blockers and hormone therapies to minors, though it makes exceptions for children who are already receiving care until they “wean off” any drugs they are taking.

May 22, 2023 Nebraska Gov. Jim Pillen (R) signed a bill that prevents doctors from prescribing puberty blockers and hormone therapy or performing gender-altering procedures on people under 19 starting October 1, with some exceptions for people with “a medically verifiable disorder of sex development”—the bill also bans abortions after 12 weeks, effective immediately, in what Pillen called “the most significant win for social conservative agenda in over a generation of Nebraska.”

May 17, 2023 Florida Gov. Ron DeSantis (R) signed a bill that prohibits physicians in the state from providing gender-affirming services for minors, including “sex-reassignment prescriptions” or medication like puberty blockers, and includes a provision restricting access for adults unless they sign a consent form (the Florida Board of Medicine previously banned gender-transition surgeries and puberty blockers for most minors in November).

May 1, 2023 Oklahoma Gov. Kevin Stitt (R)—who called for a ban on gender-affirming care last year—signed a bill that prohibits physicians in the state from providing “gender transition procedures,” including gender-reassignment surgery or prescribing puberty blockers, with a provision indicating physicians can be charged with a felony and lose their medical licenses if they violate the law.

April 28, 2023 Montana Gov. Greg Gianforte (R) signed a bill that bans “Montana children from permanent, life-altering medical procedures until they are adults,” and includes a provision stating doctors could lose their medical licenses for a year if they violate the law.

April 20, 2023 A bill signed by North Dakota Gov. Doug Burgum (R) prohibits physicians in the state from performing gender-reassignment surgeries and from prescribing gender-affirming medication, like drugs that block puberty, though it makes exceptions for minors who are currently receiving gender-affirming care, or for minors with “genetic disorder[s] of sexual development” who get parental consent.

April 5, 2023 Indiana Gov. Eric Holcomb (R) signed a bill that prohibits healthcare providers from “knowingly” providing “gender transition procedures” to minors, which include gender-reassignment surgeries, hormone therapy and puberty blockers.

April 4, 2023 A bill signed by Idaho Gov. Brad Little (R) prevents healthcare providers from providing any gender-affirming care to minors if it’s meant to “affirm” a gender identity different from their gender at birth, and violators could face up to ten years in prison.

March 29, 2023 West Virginia Gov. Jim Justice (R) signed a bill that prohibits “irreversible gender reassignment surgery” and the prescription of any “gender altering medication,” with exceptions for people who are born intersex—when a person’s reproductive organs do not neatly match a specific gender.

March 29, 2023 Republican lawmakers in Kentucky passed—after overriding Democratic Gov. Andy Beshear’s veto—a bill that prohibits healthcare providers from providing gender-affirming services to minors “for the purpose of attempting to alter the appearance or perception of the minor’s sex.”

March 23, 2023 A bill signed by Georgia Gov. Brian Kemp (R) prohibits physicians from providing hormone therapy or any gender-transition surgeries to minors—though it does make exceptions for anyone born intersex.

March 22, 2023 Physicians in Iowa were granted a six-month period to cease gender-affirming care for minors after a bill signed by Republican Gov. Kim Reynolds prohibited healthcare providers from prescribing drugs that block puberty and hormone therapy.

March 2, 2023 Tennessee Gov. Bill Lee (R) signed a bill that prohibits healthcare providers in the state from performing gender-reassignment surgeries for minors, and physicians could be sued by parents or the state.

February 18, 2023 Physicians in Mississippi are prohibited from offering gender-reassignment surgeries, drugs that block puberty or hormone therapy to minors, according to a bill signed by Republican Gov. Tate Reeves.

February 14, 2023 Healthcare providers in South Dakota could lose their medical licenses and face civil action if they provide gender-affirming care “for the purpose of attempting to alter the appearance of, or to validate a minor’s perception of, the minor’s sex,” according to a bill signed by Republican Gov. Kristi Noem.

January 28, 2023 Utah Gov. Spencer Cox (R) signed a bill that prohibits healthcare providers from providing any gender-affirming services and places an indefinite ban on access to hormone therapy and puberty blockers.

April 8, 2022 Alabama Gov. Kay Ivey (R) signed a bill that prohibits healthcare providers from performing gender-reassignment surgeries and from prescribing hormone therapy and puberty blockers, with violations punishable by up to ten years in prison—though the bill was blocked by a federal judge the following month.

March 30, 2022 A bill signed by then Arizona Gov. Doug Ducey (R) prohibits physicians from providing any gender-transition procedures to anyone under 18, though it does make exceptions for anyone who is born intersex.

April 6, 2021 Arkansas became the first state to outlaw gender-affirming care for minors after the state legislature voted to override a veto by then Gov. Asa Hutchinson (R).

300,000. That’s how many kids aged 13 to 17 identify as transgender, according to estimates from UCLA’s Williams Institute, of which nearly 27% are estimated to live in states that have banned gender-affirming care.

Chief Critic

Earlier this year, former President Donald Trump said he would assign federal agencies to “stop” healthcare providers from giving gender-affirming care—which he said was “child abuse” and “child sexual mutilation”—for minors if he was re-elected. Florida Gov. Ron DeSantis (R) has referred to gender-affirming care as “an example of woke ideology infecting medical practice.” Rep. Marjorie Taylor Greene (R-Ga.) said she wanted to introduce legislation that would block federal funding for gender-affirming services because “the Republican Party has a duty” to “be the party that protects children.” Ivey said in a statement she supported a bill prohibiting gender-affirming care in Alabama because “if the Good Lord made you a boy, you are a boy, and if he made you a girl, you are a girl.” Reynolds supported a bill because “we need to just pause” to better understand how gender-affirming care affects children. Rep. David Meade (R), speaker pro tempore of Kentucky’s House, said a ban was necessary in order to “ensure” that gender-affirming care “is not something we should be allowing until they are adults.”

Several politicians and medical organizations have pushed back against attempts to ban gender-affirming care, arguing treatment is often necessary because transgender children face higher rates of depression and suicide. The American Medical Association said, “decisions about medical care belong within the sanctity of the patient-physician relationship.” In 2018, the American Academy of Pediatrics said transgender youth experience “disproportionately high” rates of homelessness, physical violence, substance abuse and are often subjected to harassment. The Human Rights Campaign criticized Indiana lawmakers for introducing a bill banning gender-affirming care and said it was “another example of extremist politicians using their power to marginalize LGBTQ+ people, especially transgender youth.” Hutchinson , a Republican, said he vetoed a bill banning gender-affirming care because it put “a very vulnerable population in a more difficult position.” Beshear said after vetoing a bill banning gender-affirming care that the bill would “cause an increase in suicide among Kentucky’s youth” and could “endanger the children of Kentucky.” After the state legislature approved a bill that would provide state funding for gender-affirming care, Gov. Wes Moore (D-Md.) said he wanted “every person in this state to know that their authentic self is good enough.”

Access to gender-affirming care in Europe varies from country to country, as national health services have debated whether there is a lack of evidence supporting hormonal treatment for minors. England, which previously only had one facility that provided gender-affirming services, expanded access to hormone therapy and other gender-reassignment treatments after a review by the National Health Service indicated a single provider was “not sustainable.” The review also found there to be a “lack of consensus and open discussion” about gender dysphoria and how medical services should respond. Dr. Hilary Cass, who authored the review, also questioned whether children were supported if they decided against transitioning. The Swedish National Board of Health and Welfare updated its healthcare guidelines last year to prevent minors from accessing gender-affirming care, after it noted the “evidence base for hormonal interventions” for minors is “of low quality, and that hormonal treatments may carry risks.” The Finnish Health Authority issued similar restrictions , though both Finland and Sweden made exceptions for children who show evidence of “distress” from experiencing gender dysphoria.

Further Reading

Kansas Approves Ban On Gender-Affirming Care—Likely Next State To Join Wave Of State Restrictions ( Forbes )

Indiana Becomes 14th State To Ban Gender-Affirming Care—Despite GOP Governor’s Concerns About ‘Vagueness’ ( Forbes )

Kentucky Becomes 12th State To Ban Gender-Affirming Care After GOP Lawmakers Override Governor’s Veto ( Forbes )

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Sweden passes law lowering age to legally change gender from 18 to 16

Proposal sparked intense debate in country but passed with 234 votes in favour and 94 against

Sweden’s parliament has passed a law lowering the minimum age to legally change gender from 18 to 16 and making it easier to get access to surgical interventions.

The law passed with 234 votes in favour and 94 against in Sweden’s 349-seat parliament.

While the Nordic country was the first to introduce legal gender reassignment in 1972, the new proposal, aimed at allowing self-identification and simplifying the procedure, sparked an intense debate in the country.

The center-right coalition of the conservative prime minister, Ulf Kristersson, has been split on the issue, with his own Moderates and the Liberals largely supporting the law while the smaller Christian Democrats were against it.

The Sweden Democrats, the populist party with far-right roots that support the government in parliament but are not part of the government, also opposed it.

“The great majority of Swedes will never notice that the law has changed, but for a number of transgender people the new law makes a large and important difference,” Johan Hultberg, an MP representing the ruling conservative Moderate party, told parliament.

Beyond lowering the age, the new legislation is aimed at making it simpler for a person to change their legal gender.

“The process today is very long, it can take up to seven years to change your legal gender in Sweden,” Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender , Queer and Intersex Rights (RFSL), told AFP.

Two new laws will go into force on 1 July 2025: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

People will be able to change their legal gender at 16, though those under 18 will need the approval of their parents, a doctor and the National Board of Health and Welfare.

A diagnosis of “gender dysphoria” – where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as – will no longer be required.

Surgical procedures to transition would be allowed from the age of 18, but would no longer require the board’s approval. The removal of ovaries or testes will only be allowed from the age of 23, unchanged from today.

Denmark, Norway, Finland and Spain are among countries that already have similar laws.

Last Friday German lawmakers approved similar legislation, making it easier for transgender, intersex and non-binary people to change their name and gender in official records directly at register offices.

In the UK, the Scottish parliament in 2022 passed a bill allowing people aged 16 or older to change their gender designation on identity documents by self-declaration. It was blocked by the British government , a decision that Scotland’s highest civil court upheld in December.

The legislation set Scotland apart from the rest of the UK, where the minimum age is 18 and a medical diagnosis is required.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases. This is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500% since 2008, according to the Board of Health and Welfare.

While tolerance for gender transition has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal.

A poll published this week suggested almost 60% of Swedes oppose the proposal, while only 22% back it.

In a sign of the strong feelings it stirred, members of parliament spent six hours debating the proposal.

• Transgender

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'You belong here': Minnesota House passes trans health refuge bill

The Minnesota House of Representatives passed a bill early Friday by a vote of 68-62 that would prevent state courts or officials from complying with child removal requests, extraditions, arrests or subpoenas related to gender-affirming health care that a person receives in Minnesota. 

Physicians who practice gender-affirming care in Minnesota and families who’ve sought it out for their transgender children or teenagers said it would go a long way to ensure that they can continue to access treatment without fear of other states’ laws getting in the way. 

They also said it would send a message to transgender people that they are welcome in Minnesota.

Eight states – Alabama, Arkansas, Florida, Iowa, Mississippi, South Dakota, Tennessee and Utah – have issued all out bans on gender-affirming care for transgender youth, including medication and surgical services. Meanwhile, Arizona has outlawed surgical treatments and dozens of other states have bans under consideration.

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That has meant that transgender youth and their families have had to look to other states for care options.

“Forced detransition is a violence against my community that I can barely begin to imagine. That is what is happening in states across America,” bill author Rep. Leigh Finke, DFL-St. Paul, said. “To all those families across the United States that are afraid and wondering where they can go for help, Minnesota is saying we see you, we love you, and you belong here.”

Gov. Tim Walz earlier this month issued an executive order directing state agencies and officials not to comply with other state’s efforts to penalize out-of-state patients who travel to Minnesota to pursue gender-affirming care. 

But the bill’s supporters said it’s important to guarantee that protection in state law.

Minnesota physicians who provide gender-affirming care said they’ve already seen an uptick in prospective patients from states where their options have been outlawed.

Dr. Angela Kade Goepferd, chief education officer and medical director of the Gender Health program at Children's Minnesota, said young people can experience significant mental health impacts when they undergo impacts of puberty that don't align with their gender identity.

“Frequently we will talk about gender-affirming care as life saving health care. And we're not saying that to be dramatic,” Goepferd said. “We're saying that because for kids and adolescents and adults who can't access gender-affirming health care, they are at significantly higher risk of worse mental health outcomes, including suicidality.”

“So these decisions that are being taken up in state legislatures are literally putting lives at stake,” Goepferd continued.

Republican lawmakers in states that have imposed bans, as well as in Minnesota, have raised concerns about long-term impacts of gender-affirming treatments for transgender children or youth.

“The bill makes Minnesota a sanctuary state for so-called gender-affirming care, while simultaneously infringing on the fundamental right of parenting,” Minnesota Rep. Peggy Scott, R-Andover, said ahead of the floor debate Thursday. “It allows children, regardless of age, to seek and receive radical medical treatments.”  

While those comments or concerns permeate the national dialogue around gender-affirming care for transgender and gender diverse people, they don’t square with reality, physicians said.

Major medical associations support gender-affirming care and note it improves mental health outcomes in the short and long term. And while lawmakers carrying proposals to ban gender-affirming care tend to focus on surgical options, providers note that only in rare instances do transgender people under age 18 qualify for surgical treatments.

• What is gender-affirming health care? 'Trans refuge' bill would help kids get it
• January MN bill aims to create legal refuge for trans youth seeking gender-affirming care
• Earlier Walz moves to protect those seeking gender-affirming care

Goepferd said Children’s Minnesota doesn’t perform gender-affirming surgeries on patients under 18 years old. Patients that come in before puberty undergo counseling to check in about how they’re feeling and developing. After kids reach puberty, typically between ages 12 and 16, they can become eligible for reversible puberty-blocking hormones.

After that, transgender and gender diverse youth can seek out gender-affirming surgeries. But that’s a process that takes time, Goepferd said.

“This care is not new, this care is not fast. This care is evidence-based. It is age and developmentally appropriate,” Goepferd said. “The controversy around this care is new, and has been constructed over the last one to two years. But this care itself is not new. And the care itself is not controversial.”

“So the bottom line is that all kids deserve to access the health care they need and that should not depend on the state that you live in,” Goepferd continued.

Ahead of Thursday’s floor debate, LGBTQ+ families and allies, along with medical providers held up signs outside the House chamber that said “trans rights are human rights” and “you belong.”

And they led a call and response cheer. “When trans kids are under attack, what do we do? Stand up, fight back,” they cheered.

GOP lawmakers and conservative groups offered a prayer outside the House chambers and greeted lawmakers with signs that said “parents know best” as they entered the chamber.

The Minnesota bill is set to be heard in the Senate Judiciary and Public Safety Committee on Friday, and DFL leaders have said it is a priority. Gov. Tim Walz has said he will sign the bill into law if it reaches his desk.

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Supreme Court Clears Way, for Now, for Idaho to Ban Transgender Treatment for Minors

The Idaho attorney general had asked the justices to move swiftly to let the state law, which would ban gender-affirming medical care for minors, go into effect.

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By Abbie VanSickle

Reporting from Washington

The Supreme Court temporarily allowed Idaho on Monday to enforce a ban on gender-affirming treatment for minors, effectively suggesting that some justices appear comfortable with wading into another front in the culture wars.

In siding with state officials who had asked the court to lift a block on the law as an appeal moves forward, the justices were sharply split, with a majority of the conservatives voting to allow the ban to take effect over the objections of the three liberals.

The court said the ban would apply to everyone except for the plaintiffs who brought the challenge.

Notably, the opinions focused not on transgender care, a hot-button political issue that has prompted several Republican-led legislatures to approve bills to restrict puberty-blocking drugs and hormone treatments, but on a broader legal question: universal injunctions.

Universal injunctions are when a single judge issues a sweeping decision that applies beyond those directly involved in the dispute. Some justices have signaled an interest in looking at the tactic.

Although orders in response to emergency applications often include no reasoning, the justices in this case divided into several factions.

The decision included concurrences by Justice Neil M. Gorsuch, who was joined by Justices Samuel A. Alito Jr. and Clarence Thomas, and Justice Brett M. Kavanaugh, who was joined by Justice Amy Coney Barrett. Chief Justice John G. Roberts Jr. did not note a position.

Justice Ketanji Brown Jackson dissented and was joined by Justice Sonia Sotomayor. Justice Elena Kagan noted a dissent.

The Idaho law, passed by the state’s Republican-controlled Legislature, makes it a felony for doctors to provide transgender medical care for minors, including hormone treatment.

States around the country have pushed to curtail transgender rights. At least 20 Republican-led states, including Idaho, have enacted legislation that limits access for gender transition care for minors.

In his concurrence, Justice Gorsuch said the use of a universal injunction “meant Idaho could not enforce its prohibition against surgeries to remove or alter children’s genitals, even though no party before the court had sought access to those surgeries or demonstrated that Idaho’s prohibition of them offended federal law.”

He wrote that the case broached the use of such injunctions, “a question of great significance that has been in need of the court’s attention for some time.” In recent years, he added, lower courts had overstepped their bounds by seeking “to govern an entire state or even the whole nation from their courtrooms.”

In her dissent, Justice Jackson also honed in on similar questions. But she wrote that the case, particularly given that it was brought on the emergency docket, was “not be the place to address the open and challenging questions that that issue raises.”

If there was any point of agreement in the case, it seemed to be a growing frustration with the number and scope of cases brought on the court’s emergency docket.

Justice Jackson noted that she saw “some common ground” with her conservative colleagues by agreeing that “our emergency docket seems to have become increasingly unworkable.”

The American Civil Liberties Union, which represents the plaintiffs in the case, denounced the outcome, saying it was “an awful result for transgender youth and their families across the state.”

“Today’s ruling allows the state to shut down the care that thousands of families rely on while sowing further confusion and disruption,” it said in a statement.

The Idaho attorney general, Raúl Labrador, a Republican and former member of Congress who helped found the conservative House Freedom Caucus, celebrated the decision.

“Denying the basic truth that boys and girls are biologically different hurts our kids,” Mr. Labrador said. “No one has the right to harm children, and I’m grateful that we, as the state, have the power — and duty — to protect them.”

Idaho officials had appealed to the Supreme Court after the U.S. Court of Appeals for the Ninth Circuit, in San Francisco, upheld a temporary block on the law as litigation continues in lower courts.

The law, the Vulnerable Child Protection Act, makes it a crime for medical providers to offer medical care to transgender teenagers.

Mr. Labrador, in his emergency application, said that the case raised a recurring question that a majority of the justices had expressed interest in: whether a court can enact a universal injunction.

Mr. Labrador contended that a federal court erred in applying the freeze so expansively. “The plaintiffs are two minors and their parents, and the injunction covers two million,” he wrote.

Temporarily barring the law meant “leaving vulnerable children subject to procedures that even plaintiffs’ experts agree are inappropriate for some of them,” he added.

Mr. Labrador continued, “These procedures have lifelong, irreversible consequences, with more and more minors voicing their regret for taking this path.”

The plaintiffs had asserted that the case was not the right vehicle for addressing concerns about universal injunctions.

That is because the four plaintiffs are anonymous, referred to only by pseudonyms. If the court narrowed the temporary pause on the Idaho law to apply only to those directly involved in the lawsuit, the plaintiffs, including minors, would be forced to “disclose their identities as the transgender plaintiffs in this litigation to staff at doctors’ offices and pharmacies every time they visited a doctor or sought to fill their prescriptions.”

Abbie VanSickle covers the United States Supreme Court for The Times. She is a lawyer and has an extensive background in investigative reporting. More about Abbie VanSickle

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• Health Law & Managed Care
• Civil Rights

On May 4, 2023,  SB 254  passed the Florida Senate by a safe majority vote of 83 to 28 and is now on Governor DeSantis’s desk for approval. Once signed (expected shortly) , this law will take  immediate effect  and disrupt the provision of gender affirming care in the state of Florida. Specifically, the law will:

• prohibit the provision of sex-reassignment prescriptions or procedures to minors;
• impact the ability to prescribe sex-reassignment medications to adults via telemedicine; and
• prohibit state funds from paying for sex-reassignment prescriptions or procedures.

This law only impacts prescriptions and procedures and will not impact the provision of other types of care, such as behavioral health services.

Prohibition of Treatment of Minors

The proposed law broadly prohibits any sex-reassignment prescriptions and procedures for patients younger than 18 years of age regardless of parental consent or physician recommendation. The only exception to the prohibition is for patients who commenced any prescriptions or procedures prior to or on the date of when the proposed law is signed. In these cases, the Board of Medicine and the Board of Osteopathic Medicine must adopt emergency rules dictating the required informed consent requirements from the patient’s parent or legal guardian and the provision of professional counseling services by a psychiatrist or psychologist for the patient. Willful violation of this law by a health care practitioner will be considered a felony of the third degree.

Additionally, the law would allow Florida courts to take emergency temporary jurisdiction of a child present in this state if necessary to prevent a minor from either being at risk of or currently undergoing any sex-reassignment prescriptions or procedures.

In Person Informed Consent for Treatment of Adults

Under the proposed law, a patient over 18 must provide voluntary informed consent, in writing, before obtaining sex-reassignment prescriptions or procedures. For the consent to be considered informed, the prescribing or administering physician must, while “physically present in the same room”:

• Inform the patient of the nature and risks;
• Provide the informed consent forms adopted by the Board of Medicine and the Board of Osteopathic Medicine; and
• Receive the patient’s written acknowledgement before the prescription or procedure is prescribed, administered, or performed.

The treating physician only needs to obtain consent once for a prescription and any renewals, but separate consent will be needed before the physician prescribes any new pharmaceutical products. Further, only a physician can obtain consent (i.e., nurse practitioners and physician assistants cannot satisfy the consent requirements) and failure to do so will be classified as a misdemeanor of the first degree.

The “physically present in the same room” requirement means physicians may not provide the consent via telehealth technologies which could significantly restrict a patient’s ability to receive needed prescriptions via telemedicine.

State Funds

Once the bill is signed into law, state funds cannot be used to pay for sex-reassignment prescriptions or procedures.

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JASON RANTZ

Rantz: WA laws now allow teen gender reassignment surgery without parental consent

Jan 10, 2022, 6:00 PM | Updated: Feb 10, 2023, 8:17 am

L.G.B.T. activists and their supporters rally in support of transgender people on the steps of New York City Hall in 2018. (File photo by Drew Angerer/Getty Images)

(File photo by Drew Angerer/Getty Images)

BY JASON RANTZ

AM 770 KTTH host

Washington state now appears to allow minors to undergo life-changing gender reassignment surgery without parental consent.

Under a new law, health insurers must cover “gender-affirming” care, including surgical treatments that were previously denied coverage. Democrats rejected a proposal to apply the new law to patients over 18 years old.

It’s one in a series of new laws that, taken together, allow children as young as 13 years old to make serious health care decisions. The consequences are immense.

Another law making it easier for minors to transition without parental guidance

Last year, via SB 5889 , Washington Democrats forced insurers to cover gender dysphoria treatment and gender-affirming care for minors between 13 and 17, without parental consent. It mandates that insurers deal directly with the patient without requiring the policyholder’s authorization.

It builds on SB 5904 , which provides outpatient mental health treatment without parental consent for the same age group.

All communication must go directly to the patient. The insurer may not disclose the patient’s medical information to outside parties, like the policyholder, unless given permission. The policyholder, in this case, is the parent.

The standard of care for gender dysphoria in youth is outlined by the World Professional Association for Transgender Health (WPATH). It includes everything from puberty-blocking hormones and speech therapy, to laser hair removal and counseling on binding. But it also asks doctors to affirm the choice of some to undergo surgical procedures to help them match their gender identity.

For some transgender patients, WPATH says, “relief from gender dysphoria cannot be achieved without modification of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity.”

“Mental health professionals should not impose a binary view of gender. They should give ample room for clients to explore different options for gender expression. Hormonal or surgical interventions are appropriate for some adolescents, but not for others,” WPATH notes.

Technical update on language downplays the seriousness of law

The new law is just a minor update to technical terminology on the surface. But it’s much more than that.

SB 5313 bans an insurance provider from categorically rejecting cosmetic, gender-affirming treatments when deemed medically necessary by a health care provider and when prescribed to a patient, consistent with their gender identity.

Up until this law, gender reassignment surgery and other procedures like facial reconstruction or laser hair removal were considered cosmetic by health insurance companies. Due to its classification as cosmetic, health insurers did not usually cover the procedures, even when doctors medically recommended them.

The bill was signed into law by Governor Jay Inslee in 2021 and went into effect on Jan. 1, 2022.

Is this about bigotry?

The bill’s sponsor, State Senator Marko Liias (D-Lynnwood), argued at the time of its passage that it was in response to other states banning treatment for minors. He labeled the bans as “transphobic.”

“I am proud that our state is sort of standing up to this hysteria sweeping the country of intolerance and hatred of trans people,” Liias told Crosscut. “We are going the opposite direction saying that, here, people are welcome and we support them.”

But the direction that Liias is going means cutting parents out of the decision-making process, allowing a child to alter their body permanently.

It’s also a curious move since Washington law bans minors from using tanning beds . Lawmakers, including Liias, voted for that ban to protect children from the harmful effects of UV rays. Now Democrats allow your child to go through feminizing hormone therapy and some surgical procedures independently.

One Senate Republican supported the bill, and all House Republicans rejected it.

Liias finally weighs in with an evasive response

Initially, Liias did not respond to multiple requests for comment.

Instead, the Senate Democratic Caucus spokesperson sent a statement arguing “there is not a specific mention of gender affirming care in statute.” She argues that means gender reassignment surgery would still need parental consent.

But SB 5889 mentions explicitly “gender dysphoria” and “gender affirming care.” And Liias’ bill covers “gender affirming” surgical procedures.

When asked to clarify their statement with the language in the bills, the spokesperson did not respond. But at the behest of the Senate Democratic Caucus, Liias finally responded.

I asked Liias if he supports gender reassignment surgery for minors either with or without parental consent. He would not answer directly but implied he supports it with or without parental consent.

“There is not a short or simple answer on what care is appropriate for which individuals. In short, I support the ability of all trans people to access medically necessary care. Medical providers use established standards of care in consultation with patients and their caregivers as appropriate,” Liias wrote in an email to the Jason Rantz Show on KTTH.

He linked to the American Academy of Pediatrics with an example of pediatric care guidelines. It does offer guidance to avoid surgery, such as “pubertal suppression in children.”

But it also notes that the process of gender affirmation may include: “‘top’ surgery (to create a male-typical chest shape or enhance breasts); ‘bottom’ surgery (surgery on genitals or reproductive organs); facial feminization and other procedures.”

“I don’t believe that lawmakers or insurance companies should make determinations of what care is appropriate, that decision is best left with our health agencies, medical professionals and patients,” Liias says, failing to mention parents.

Republicans saw this coming

Republicans argue the current laws do not require parental consent for these surgical procedures if the patient is between 13 and 18, assuming a patient is able to find a willing doctor.

“This is wrong — 13-year-olds are not mature enough to make gender reversal surgery decisions and need parental support during this time,” State Representative Michele Caldier (R-Port Orchard) told the Jason Rantz Show on KTTH. “The same legislators who pushed the age of purchase of tobacco products from age 18 to 21, now claim 13-year-olds are able to make the solo decision whether to get their trachea shaved or a mastectomy.”

“I am a foster parent who takes in hard-to-place teens. These kids need my help for simple day-to-day tasks. I couldn’t imagine them making life-changing decisions without my support or their parent’s support,” Caldier added.

The direct intent of SB 5313 wasn’t to offer surgical treatment to minors. But combined with previously passed legislation, it’s now possible.

Republican lawmakers saw this coming. It’s why they saw only one defector.

State Senator Phil Fortunado (R-Auburn) attempted to amend SB 5313. His amendment inserted language that would deny gender-affirming treatment to patients under 18. But Democrats, who have control of the legislature, rejected it.

On the House side, Caldier tried to at least tighten the language.

Instead of blanket support of cosmetic gender-affirming treatment, Caldier wanted a slightly higher bar to be met. Procedures would only be covered “if the treatment or services will improve the overall mental health of the enrollee.”

Again, Democrats rejected it.

This isn’t about trans rights

Many Democrats who support this kind of legislation try to silence critics by labeling them transphobic and intolerant. It’s a cheap and disingenuous attempt to shut down reasonable opposition.

Parents have the biggest role to play in the well-being of their children. But progressive lawmakers and activists pretend parents are abusive if they dare to question their kid’s position that they’re transgender.

No, 13-year-olds aren’t mature enough at that age to determine they can handle a gender reassignment surgery.

Unfortunately, unless a parent immediately and unquestionably accepts their kid’s feelings at the time, the Left deems them to be unfit parents. And they believe that if a child even suspects their parents might say no to a life-altering surgery, the child should have the right to move forward on their own.

It’s an easy position for politicians or activists to take when they don’t have to deal with the consequences the way a child and his or her family would.

This isn’t responsible lawmaking, either

Will there be a rush of 13-year-olds getting gender reassignment surgery without parental consent as a result of this law? No. But this is another step Democrats are taking to redefine gender. And, in time, teenage gender reassignment surgeries could become more frequent.

There are endless stories of people regretting their transitions . They felt betrayed by doctors who refused to question their decisions, eager to appear supportive rather than inform them of the consequences. When outlets tell these stories, progressive activists scream claims of bigotry.

There are also clear examples of children shutting out parents who are supportive.

Most teens go through a phase of being untrusting of parents or wanting to keep something private — issues much less sensitive or serious than gender reassignment surgery.

Breaking the bond between child and parent

These laws intentionally disconnect a parent and child. When did breaking up a family connection lead to societal benefits?

The legislature could have easily created a carve-out for minors who have a legitimate reason to keep some treatment private from abusive parents. But they chose not to. This isn’t about the child, it’s about a greater political movement. And these children are being used to forward it.

Teens who question their gender identity deserve our support and compassion. I can’t imagine what it’s like to have that particular feeling. But I certainly know what teenage years feel like as someone who is gay. It can be awkward and isolating even when you do have someone to talk to.

These Democrat laws do not serve these children. They’re being deprived of the support they’re owed by adults using them to make political statements. Having gender identity conversations with loving parents, however awkward, is better than letting an activist politician push teens down a path they’re certainly not ready to handle on their own.

Listen to the Jason Rantz Show weekday afternoons from 3–6 pm on KTTH 770 AM (HD Radio 97.3 FM HD-Channel 3). Subscribe to the podcast here . Follow  @JasonRantz   on   Twitter,    Instagram , and  Facebook . Check back frequently for more news and analysis.

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Gender Reassignment Discrimination

Anne morris.

• 7 September 2020

IN THIS SECTION

As an employer, it is illegal to treat someone unfairly at work because they intend to undergo, are undergoing or have undergone gender reassignment. It is also unlawful to fail to take timely and appropriate action when others at work discriminate against, or bully or harass someone else, because they are transsexual.

Below we look at what the law says about gender reassignment discrimination in the workplace, including what happens when employers get this wrong and the steps that you can put in place to help prevent this type of discrimination .

This is a developing area of law, with a recent tribunal decision finding that protection of non-binary and gender-fluid individuals falls within the scope of gender reassignment under the Equality Act.

What is gender reassignment discrimination?

Gender reassignment discrimination is where someone is treated unfairly because they are ‘transsexual’, ie; someone whose gender identity is different from the gender assigned to them when they were born. Other more commonly used terminology could include transgender, trans male/female, or simply trans.

The unfair treatment could be a one-off action or series of actions, or even as a result of a workplace rule or policy that is applied equally to everyone but puts a transsexual or trans person at a particular disadvantage.

To be protected from gender reassignment discrimination, a person does not need to have undergone any specific treatment or surgery to change from their birth sex to their preferred gender. This is because changing their physiological or other gender attributes is a personal process rather than a medical one.

What is the law on gender reassignment discrimination?

The law relating to gender reassignment discrimination is set out under the Equality Act 2010. The Act makes it unlawful for a person to be discriminated against, or harassed or victimised , because of one or more of the nine protected characteristics , where gender reassignment is one of these.

All transsexual or trans people share the common characteristic of gender reassignment. This could be where someone who was born male has made the decision to spend the rest of her life as a woman, or vice versa.

To be afforded the protection from discrimination, harassment and victimisation, the person can be at any stage in the transition process, from planning to reassign their gender, to undergoing or having completed this process. This includes anyone who has started the process but then decided not to continue.

Protection is also afforded to anyone dressing in a certain way to express their chosen gender, although those who only choose to temporarily adopt the appearance of the opposite gender, such as transvestites, are not protected under the legislation. This is because their cross-dressing is not part of the process of transitioning to live as their non-birth gender.

What employment protections do transsexual employees have?

Under the Equality Act, all transsexual employees are afforded protection from four main types of discriminatory behaviour in the workplace:

• Direct discrimination: where you treat an employee less favourably than you treat or would treat others because they are proposing to undergo, is undergoing or has undergone all or part of a process for the purpose of reassigning their sex by changing physiological or other gender attributes.
• Indirect discrimination : where a workplace provision, criterion or practice that applies equally to everyone puts a transsexual employee at a disproportionate disadvantage when compared with others.
• Harassment: where a transsexual employee is subjected to unwanted conduct at work because of their gender reassignment, and this has the purpose or effect of violating their dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment.
• Victimisation: where someone suffers from detrimental treatment at work because they have made or supported a complaint about harassment or gender reassignment discrimination at work, or it is believed they have or may make or support such a complaint.

The Act applies to all employees, as well as job applicants, trainees, contract workers and office holders, such as company directors and partners. The Act also covers all areas of employment including recruitment, training and promotion, terms and conditions of employment, redundancy and dismissal.

Examples of gender reassignment discrimination

Direct gender reassignment discrimination.

Direct gender reassignment discrimination is where you treat someone at work worse than another person in a similar situation because they are trans. For example, having found out that an employee intends to spend the rest of their life living as a different gender, you decide to transfer them into another position, against their wishes, so they no longer have a customer-facing role.

Direct discrimination also covers the following scenarios:

• Discrimination by perception: where you discriminate against a person because you believe they are trans, even if that perception is incorrect, for example, where they occasionally cross-dress or is gender variant.
• Discrimination by association : where you discriminate against a person for being connected with someone who is, or is wrongly thought to be, transsexual. This could include a co-worker, family member or friend.

Indirect gender reassignment discrimination

Indirect gender reassignment discrimination refers to the application of a rule or policy at work that, on the face of it, applies equally to persons who are not transsexual but which particularly disadvantages transsexual or trans people.

An example of indirect discrimination might be where you have a company policy for an employee’s ID tag to always feature their photograph as it appeared on the day they joined the company. However, because they have changed their gender since then, this might cause them significant embarrassment.

Harassment because of gender reassignment

The definition of harassment under the Act is wide enough to include all types of unwanted conduct because of gender reassignment. This could include nicknames, insults, abusive language, threats, jokes, banter, gossip, asking intrusive or inappropriate questions, excluding or ignoring someone, or even excessive monitoring or excessive criticism of someone’s work.

It does not matter if the harassment is intentional or unintentional, and doesn’t necessarily need to be aimed at the person witnessing it. Examples of this might include the telling or tolerating of trans-phobic jokes and the use of derogatory trans-phobic terms as part of an accepted workplace culture.

As an employer, you are potentially liable for the discriminatory acts of your employees where those employees are acting in the course of their employment. This is known as vicarious liability. You are also liable for the harassment of your staff by third parties, such as clients, customers or suppliers.

This means that if you are aware that a trans person is being harassed at work, either by a member of staff or a third party, and you fail to take reasonable steps to prevent this from happening again, you may be breaking the law.

Victimisation because of gender reassignment

This is where someone at work is subjected to a detriment because they have made, tried to make, helped someone else to make or assumed to have made, a complaint or grievance of discrimination on the grounds of gender reassignment.

A detriment could include, for example, an employee being denied a pay rise or promotion because they have made allegations of gender reassignment discrimination, or where they have given evidence in support of a complaint made by a transsexual person, even though they themselves are not transsexual.

What are the special protections relating to absences from work?

Under the Equality Act 2010, there are special protections relating to absences from work because of gender reassignment.

This means that if someone is absent from work because of gender reassignment you cannot treat that person less favourably than you would treat any other person off work due to sickness or injury, or due to some other reason and it is not reasonable to treat the transsexual person less favourably.

For example, if you refuse, without good reason, to let someone have time off work to undergo treatment for gender reassignment, or you permit them to take time off but pay that person less than they would have received if they were off sick, this is likely to amount to direct discrimination under the Act.

This protection extends to any medical appointment associated with the gender reassignment process, including taking time off for counselling.

Can gender reassignment discrimination ever be justified?

Direct gender reassignment discrimination, harassment and victimisation can never be justified. However, there are certain circumstances in which indirect discrimination can be objectively justified , as long as you can show that the treatment is a proportionate means of achieving a legitimate aim.

The process of determining whether discrimination is justified involves weighing up the legitimate needs of your business against the discriminatory effect on the group of employees who are trans. Where the same aim could have been achieved in a less discriminatory way, the discrimination cannot be justified.

In rare cases, there may also be strict occupational requirements that preclude a transsexual person from applying, although you would need to show that ‘not being trans’ is crucial to the role. This could be, for example, roles in organised religion, where being trans would not comply with the doctrines of that religion.

Equally, there may be cases where a person is required to be transsexual, for example, a gender identity support leader, although again, ‘being trans’ in this instance, must be crucial and not just one of many important factors.

It is also important to note that you can take positive steps to support transgender people who are under-represented in your workforce or otherwise disadvantaged. This could be by way of encouraging applications from trans people or providing special training. This is known as taking positive action .

What are the consequences of gender reassignment discrimination?

If you get the law wrong in relation to gender reassignment discrimination, even if you are trying to take positive steps to assist transsexual people, or you unintentionally discriminate against a trans person, you may find yourself facing a claim for unlawful discrimination before an employment tribunal.

The importance of understanding and preventing all forms of discrimination at work should never be underestimated. The cost to your business in terms of reputational damage and legal proceedings can be significant.

The Equality Act does not require any minimum length of employment, or any employment at all in the case of a job applicant, for an unlawful discrimination claim to be made. The tribunal also has the power to award one or more of the following three remedies if it finds there has been discrimination:

• A declaration setting out the rights of the parties
• An uncapped award of damages, including an award for injury to feelings and to compensate the individual for any financial loss suffered
• A recommendation that you should take certain steps to remove or reduce the discrimination in your workplace

How can employers prevent gender reassignment discrimination?

Employers should take steps to help prevent gender reassignment discrimination and minimise the possibility of workplace issues, grievances or tribunal claims.

These steps could include a programme of equality and diversity training for all your staff on how different forms of gender reassignment discrimination can arise; putting in place appropriate procedures to deal with grievances, both informally and formally; and reviewing your workplace policies on equal opportunities, dignity at work, and bullying and harassment.

In this way you will help to create a positive workplace culture in which gender reassignment discrimination is not tolerated, and victims or witnesses of discrimination feel able to report any complaints without fear of reprisal.

Need assistance?

DavidsonMorris’ employment lawyers can help with all aspects of workplace discrimination. Working closely with our specialists in HR , we can advise on steps to improve diversity and equality in your organisation, while minimising the legal risk of discrimination claims. For help and advice, speak to our experts .

Gender reassignment discrimination FAQs

Gender reassignment discrimination takes place when someone is treated unfairly on the basis of their actual or proposed gender reassignment. The unfair treatment could be a one-off action or a blanket workplace rule or policy that puts a transsexual or trans person at a particular disadvantage.

What are the different types of gender reassignment discrimination?

There are four main types of gender reassignment discrimination set out under the Equality Act 2010. These include direct discrimination, indirect discrimination, harassment and victimisation. The Act also affords trans people special protection from being treated less favourably in cases of absences from work because of gender reassignment.

What discrimination rights do trans employees have?

Trans employees have the right not to be treated less favourably at work, put at a disadvantage, or harassed or victimised, because they are transsexual, or perceived to be or connected with someone who is trans.

Last updated: 7 September 2020

Founder and Managing Director Anne Morris is a fully qualified solicitor and trusted adviser to large corporates through to SMEs, providing strategic immigration and global mobility advice to support employers with UK operations to meet their workforce needs through corporate immigration.

She is a recognised by Legal 500 and Chambers as a legal expert and delivers Board-level advice on business migration and compliance risk management as well as overseeing the firm’s development of new client propositions and delivery of cost and time efficient processing of applications.

Anne is an active public speaker, immigration commentator , and immigration policy contributor and regularly hosts training sessions for employers and HR professionals

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About DavidsonMorris

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Led by Anne Morris, one of the UK’s preeminent immigration lawyers, and with rankings in The Legal 500 and Chambers & Partners , we’re a multi-disciplinary team helping organisations to meet their people objectives, while reducing legal risk and nurturing workforce relations.

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New Federal Rule Bars Transgender School Bathroom Bans, but It Likely Isn't the Final Word

A new federal rule seeks to clarify that a law against sex discrimination at schools includes gender identity, too

New Federal Rule Bars Transgender School Bathroom Bans, but It Likely Isn't the Final Word

FILE - A protester outside the Kansas Statehouse holds a sign after a rally for transgender rights on the Transgender Day of Visibility, March 31, 2023, in Topeka, Kan. A new rule from President Joe Biden's administration assuring transgender students be allowed to use the school bathrooms that align with their gender identity could conflict with laws in Republican-controlled states that seek to make sure they can't. (AP Photo/John Hanna, File)

A new rule from President Joe Biden's administration blocking blanket policies to keep transgender students from using school bathrooms that align with their gender identity could conflict with laws in Republican-controlled states.

The clash over bathroom policy and other elements of a federal regulation finalized last week could set the stage for another wave of legal battles over how transgender kids should be treated in the U.S.

In recent years, transgender people have gained visibility and acceptance in the U.S. — and some conservative officials have pushed back.

Most GOP-controlled states now have laws reining in their rights. Measures include laws to keep transgender girls out of girls school sports, limiting which school bathrooms transgender people can use, requiring school staff to notify parents if their student identifies in school as transgender, and barring school staff from being required to use the pronouns a transgender student uses.

Most of those policies have been challenged in court.

Here's a look at the new regulation, the states' laws and what could happen next.

Photos You Should See - April 2024

WHAT'S THE HEART OF THE REGULATION?

The 1,577-page regulation finalized last week seeks to clarify Title IX, the 1972 sex discrimination law originally passed to address women's rights and applies to schools and colleges that receive federal money.

The regulations, which are to take effect in August, spell out that Title IX bars discrimination based on sexual orientation and gender identity, too.

Many Republicans say this wasn't the intent of the law.

The new rules also provide more protections to students who make accusations of sexual misconduct.

RULE CONTRADICTS BATHROOM LAWS

At least 11 states have adopted laws barring transgender girls and women from using girls' and women's bathrooms at public schools.

The new regulation opposes those sweeping policies.

It states that sex separation at schools isn't always unlawful. However, the separation becomes a violation of Title IX's nondiscrimination rule when it causes more than a very minor harm on a protected individual, “such as when it denies a transgender student access to a sex-separate facility or activity consistent with that student’s gender identity.”

The laws are in effect in Alabama, Arkansas, Florida, Iowa, Kansas, Kentucky, North Dakota, Oklahoma and Tennessee. A judge’s order putting enforcement on hold is in place in Idaho. A prohibition in Utah is scheduled to take effect July 1.

RULE ALLOWS PARENTAL NOTIFICATION REQUIREMENTS

At least seven states have laws or other policies calling for schools to notify parents if their children are transgender.

The regulation seems to authorize those requirements, stating that “nothing in these final regulations prevents a recipient from disclosing information about a minor child to their parent who has the legal right to receive disclosures on behalf of their child.”

The requirements are already law in Alabama, Arizona, Arkansas, Idaho, Indiana and North Carolina. The Arizona law requires schools to provide information to parents but does not specifically include details about students' gender expression or sexuality. Virginia asked schools to provide guidance to the state's school districts to adopt similar policies, though they're not written into state law.

ARE PRONOUN RESTRICTIONS LEGAL? IT DEPENDS

At least four states — Florida, Kentucky, Montana and North Dakota — have laws intended to protect from discipline teachers and/or students who won't use the pronouns transgender or nonbinary students use.

The regulations wrestle with this, finding that “harassing a student — including acts of verbal, nonverbal, or physical aggression, intimidation, or hostility based on the student’s nonconformity with stereotypical notions of masculinity and femininity or gender identity — can constitute discrimination on the basis of sex under Title IX in certain circumstances.”

But they also spell out that “a stray remark” does not constitute harassment and seek to protect the right of free speech.

THE BIG DEBATE: SPORTS PARTICIPATION

The new rules don't specifically mention whether states can ban transgender girls from girls sports competitions. The Biden administration has put on hold a policy that would forbid schools from having outright bans.

State laws that contain such bans have been adopted in at least two dozen states in the name of preserving girls sports. But judges have paused enforcement of some of them, including in a ruling last week that applies only to one teenage athlete in West Virginia.

While the new rules are not specific to sports participation, advocates on both sides believe they could apply.

“They may be saying that this doesn't address it, but through the broad language they’re using, the ultimate result is you have to allow a boy on a girls team,” said Matt Sharp, a lawyer with Alliance Defending Freedom, falsely identifying transgender girls as boys. Alliance Defending Freedom is a conservative group that has represented female athletes challenging sports participation by transgender women and girls.

“This document gives a good sense that says you can’t have a rule that says, ‘If you’re transgender, you can’t participate,’” said Harper Seldin, an American Civil Liberties Union lawyer.

WHAT HAPPENS NOW?

Lawsuits, probably.

After the rules were unveiled last week, Tennessee Attorney General Jonathan Skrmetti posted on X that “TN is prepared to defend Title IX & protect against unlawful regulations that redefine what sex really means.”

“We absolutely plan to challenge this betrayal of women in court,” Florida Attorney General Ashley Moody said in a statement Monday.

Oklahoma Attorney General Gentner Drummond submitted comments critical of the rule before it was finalized.

Over the last two decades, attorneys general have frequently sued the opposing party's president over rules and executive orders.

Sharp of Alliance Defending Freedom said his group is still dissecting the federal rules but does represent groups that could be affected, including female athletes and religious schools and could sue over aspects of the rules. He expects states to do the same thing.

“I don’t think a lot of states want to wait until the federal government enforces this,” he said.

The ACLU's Seldin said his organization will watch carefully how the rules play out.

“What do theses laws and regulations mean in terms of transgender youth and transgender students who find themselves attacked in every aspect of their lives?” he asked.

___ Associated Press reporter Brendan Farrington in Tallahassee, Florida; Jonathan Mattise in Nashville, Tennessee; and Sean Murphy in Oklahoma City contributed to this article.

Copyright 2024 The  Associated Press . All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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Sweden votes on controversial gender reassignment law

Sweden was the first country to introduce legal gender reassignment in 1972, but a proposal to lower the minimum age from 18 to 16 to be voted on by parliament Wednesday has sparked controversy.

Issued on: 17/04/2024 - 04:31

The debate has also weakened conservative Prime Minister Ulf Kristersson's standing, after he admitted to caving into pressure from party members on the issue.

Beyond lowering the age, the proposals also aim to make it simpler for a person to change their legal gender. 

"The process today is very long, it can take up to seven years to change your legal gender in Sweden ," Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL), told AFP.

Under the proposal, two new laws would replace the current legislation: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

If parliament adopts the bill as expected on Wednesday, people will be able to change their legal gender starting at the age of 16, though those under 18 will need the approval of their parents, a doctor, and the National Board of Health and Welfare.

A diagnosis of "gender dysphoria" -- where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as -- will no longer be required.

Surgical procedures to transition would, like now, be allowed from the age of 18, but would no longer require the Board of Health and Welfare's approval.

The removal of ovaries or testes would however only be allowed from the age of 23, unchanged from today. 

Gender dysphoria surging 

A number of European countries have already passed laws making it easier for people to change their legal gender.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases.

The trend is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500 percent since 2008, according to the Board of Health and Welfare.

While tolerance for gender transitions has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal, and academics, health care professionals and commentators have come down on both sides of the issue.

A poll published this week suggested almost 60 percent of Swedes oppose the proposal, while only 22 percent back it. 

Some critics have expressed concerns about biological males in women's locker rooms and prisons, and fear the legal change will encourage confused youths to embark down the path toward surgical transitions.

Others have insisted that more study is needed given the lack of explanation for the sharp rise in gender dysphoria.

Deep divisions 

"There is a clear correlation with different types of psychiatric conditions or diagnoses, such as autism," Annika Strandhall, head of the women's wing of the Social Democrats (S-kvinnor), told Swedish news agency TT. 

"We want to pause this (age change) and wait until there is further research that can explain this increase" in gender dysphoria cases.

RFSL's Ponkala disagreed, saying the simplified process was important for transgender people, a "vulnerable" group.

"They face a lot of risks... We see that the political climate has hardened," he said. 

Kristersson, the prime minister, has defended the proposal as "balanced and responsible".

But he has also admitted he wanted to keep the age at 18 but gave in to strong forces in his party.

His own government has been split on the issue, with the Moderates and the Liberals largely in favour and the Christian Democrats and Sweden Democrats against. 

He has had to seek support from the left-wing opposition to get the proposal through parliament.

If adopted, the new law would come into force on July 1, 2025.

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Applications for gender recognition certificate

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3A. Alternative grounds for granting applications

3B. Evidence for granting applications on alternative grounds

3C. Alternative grounds for granting applications: Scotland

3D. Evidence for granting applications on alternative grounds: Scotland

3E. Alternative grounds for granting applications: Scotland (English and Welsh and Northern Ireland residents)

3F. Evidence for granting applications on alternative grounds: Scotland (English and Welsh and Northern Ireland residents)

4. Successful applications

Issue of full certificate after interim certificate: applicant married or a civil partner

4A. Married person or civil partner with interim certificate: issue of full certificate

4B. Application under section 4A: death of spouse or civil partner

4C. Married person or civil partner with interim certificate: issue of full certificate (Scotland)

4D. Application under section 4C: death of spouse or civil partner

4E. Married person or civil partner with interim certificate: issue of full certificate on application to the sheriff (Scotland)

4F. Death of civil partner or spouse: issue of full certificate (Scotland)

5. Issue of full certificates where applicant has been married

5A. Issue of full certificates where applicant has been a civil partner

Other provision about applications and certificates

5B. Applications by both civil partners

5C. Protected Scottish civil partnership: applications by both civil partners

5D. Protected Scottish civil partnership: power to make further provision for issue of full certificate

7. Applications: supplementary

8. Appeals etc.

Consequences of issue of gender recognition certificate etc.

10. Registration

11. Marriage

11A. Change in gender of party to marriage

11B. Change in gender of civil partner

11C. Continuity of marriage: Scotland

11D. Continuity of civil partnership: Scotland

12. Parenthood

13. Social security benefits and pensions

14. Discrimination

15. Succession etc.

16. Peerages etc.

17. Trustees and personal representatives

18. Orders where expectations defeated

20. Gender-specific offences

21. Foreign gender change and marriage

Supplementary

22. Prohibition on disclosure of information

23. Power to modify statutory provisions

24. Orders and regulations

25. Interpretation

26. Commencement

27. Applications within two years of commencement

29. Short title

Gender Recognition Panels

List of persons eligible to sit

1. (1) Subject to sub-paragraph (1A), the Lord Chancellor must, after...

2. (1) Subject to sub-paragraph (1A), the Lord Chancellor must, after...

Tenure of persons appointed to list

3. Persons on the list— (a) hold and vacate their appointments...

Membership of Panels

4. (1) The President must make arrangements for determining the membership...

5. The arrangements must ensure that a Panel determining an application...

6. (1) Where a Panel consists of more than one member,...

Staff and facilities

7. The Secretary of State may make staff and other facilities...

8. (1) The Secretary of State may pay sums by way...

8A. Delegation

Tribunals and Inquiries Act 1992

9. In Schedule 1 to the Tribunals and Inquiries Act 1992...

Disqualification

10. In Part 3 of Schedule 1 to the House of...

11. In Part 3 of Schedule 1 to the Northern Ireland...

Interim certificates: marriage

Part 1 England and Wales

1. The Matrimonial Causes Act 1973 (c. 18) is amended as...

2. In section 12 (grounds on which a marriage celebrated after...

3. In section 13 (bars to relief), after subsection (2) insert—...

4. (1) Paragraph 11 of Schedule 1 (grounds on which a...

Part 2 Scotland

5. The Divorce (Scotland) Act 1976 (c. 39) is amended as...

6. (1) In subsection (1) of section 1 (grounds on which...

7. In section 2(1) (encouragement of reconciliation), for “in an action...

Part 3 Northern Ireland

8. The Matrimonial Causes (Northern Ireland) Order 1978 (S.I. 1978/1045 (N.I....

9. In Article 14 (grounds on which a marriage celebrated after...

10. In Article 16 (bars to relief), after paragraph (2) insert—...

11. (1) Paragraph 18 of Schedule 3 (grounds on which a...

Registration

Introductory

1. In this Part— “the Registrar General” means the Registrar General...

Gender Recognition Register

2. (1) The Registrar General must maintain, in the General Register...

Entries in Gender Recognition Register and marking of existing birth register entries

3. (1) If the Registrar General receives under section 10(1) a...

Indexing of entries in Gender Recognition Register

4. (1) The Registrar General must make arrangements for each entry...

Certified copies of entries in Gender Recognition Register

5. (1) Anyone who may have a certified copy of the...

Short certificates of birth compiled from Gender Recognition Register

6. Where a short certificate of birth under section 33 of...

Gender Recognition Register: re-registration

7. (1) Section 10A of the 1953 Act (re-registration where parents...

Correction etc. of Gender Recognition Register

8. (1) Any power or duty of the Registrar General or...

Revocation of gender recognition certificate etc.

9. (1) This paragraph applies if, after an entry has been...

10. (1) Section 34(5) of the 1953 Act (certified copy of...

Regulatory reform

11. England and Wales

Registration of marriages and civil partnerships

11A. (1) The Registrar General may make regulations about—

12. In this Part— “the Registrar General” means the Registrar General...

13. (1) The Registrar General must maintain, in the General Register...

Entries in Gender Recognition Register

14. (1) If the Registrar General receives under section 10(1) a...

15. (1) The Registrar General must make arrangements for each entry...

Extracts of entries in Gender Recognition Register

16. (1) This paragraph applies in respect of an extract issued...

Abbreviated extracts of birth compiled from Gender Recognition Register

17. Where an abbreviated extract of birth under section 39E of...

Gender Recognition Register: correction, re-registration etc.

18. Section 18A(2) (decrees of parentage and non-parentage), section 20(1)(re-registration in...

19. (1) This paragraph applies if, after an entry has been...

Authentication and admissibility

20. sections 41 and 41A of the 1965 Act (authentication of...

20A. (1) The Registrar General may, with the approval of the...

21. In this Part— “the Registrar General” means the Registrar General...

22. (1) The Registrar General must maintain, in the General Register...

23. (1) If the Registrar General receives under section 10(1) a...

24. (1) The Registrar General must make arrangements for each entry...

25. (1) Anyone who may have a certified copy of the...

26. Where a short certificate of birth under Article 40 of...

27. Articles 18, 19 and 19A of the 1976 Order (re-registration...

Correction of errors in Gender Recognition Register

28. (1) Any power or duty of the Registrar General to...

29. (1) This paragraph applies if, after an entry has been...

Change of name

30. Paragraphs (4) to (6) of Article 37 of the 1976...

31. (1) Article 42 of the 1976 Order (proof of age...

32. Article 47 of the 1976 Order (fees for searches, certificates...

33. (1) The Department of Finance in Northern Ireland may by...

Effect on marriage

Marriage Act 1949 (c. 76)

1. The Marriage Act 1949 is amended as follows.

2. In section 1 (restrictions on marriage), insert at the end—...

3. After section 5A insert— Marriages involving person of acquired gender...

Matrimonial Causes Act 1973 (c. 18)

4. The Matrimonial Causes Act 1973 is amended as follows.

5. In section 12 (grounds on which a marriage celebrated after...

6. In section 13(2), (3) and (4) (bars to relief), for...

Marriage (Scotland) Act 1977 (c. 15)

7. In section 2 of the Marriage (Scotland) Act 1977 (marriage...

Family Law (Miscellaneous Provisions) (Northern Ireland) Order 1984 (S.I. 1984/1984 (N.I. 14))

8. In Article 18 of the Family Law (Miscellaneous Provisions) (Northern...

Matrimonial Causes (Northern Ireland) Order 1978 (S.I. 1978/1045 (N.I. 15))

9. The Matrimonial Causes (Northern Ireland) Order 1978 is amended as...

10. In Article 14 (grounds on which a marriage celebrated after...

11. In Article 16(2), (3) and (4) (bars to relief), for...

Benefits and pensions

Part 1 Introductory

1. This Schedule applies where a full gender recognition certificate is...

Part 2 State benefits

2. (1) In this Part of this Schedule “the 1992 Act”...

Widowed mother’s allowance

3. (1) If (immediately before the certificate is issued) the person...

Widow’s pension

4. If (immediately before the certificate is issued) the person is...

Widowed parent’s allowance

5. If (immediately before the certificate is issued) the person is,...

Long-term incapacity benefit etc.

6. If (immediately before the certificate is issued) the person is...

Pension under Part 1 of the Pensions Act 2014

6A. (1) Any question— (a) whether the person is entitled to...

Pension under Part 1 of the Pensions Act (Northern Ireland) 2015

6B. (1) Any question— (a) whether the person is entitled to...

Category A retirement pension

7. (1) Any question— (a) whether the person is entitled to...

Category B retirement pension etc.

8. (1) Any question whether the person is entitled to—

Shared additional pension

9. (1) Any question— (a) whether the person is entitled to...

Deferment of pensions

10. (1) The person’s entitlement to— (za) a state pension under...

Graduated retirement benefit: Great Britain

12. (1) The provision that may be made by regulations under...

Graduated retirement benefit: Northern Ireland

13. (1) The provision that may be made by regulations under...

Part 3 Occupational pension schemes

Guaranteed minimum pensions etc.: Great Britain

14. (1) In this paragraph “the 1993 Act” means the Pension...

Guaranteed minimum pensions etc.: Northern Ireland

15. (1) In this paragraph “the 1993 Act” means the Pension...

Equivalent pension benefits: Great Britain

16. (1) The provision that may be made by regulations under...

Equivalent pension benefits: Northern Ireland

17. (1) The provision that may be made by regulations under...

Sex discrimination

Part 1 Great Britain

1. Great Britain

2. Great Britain

3. Great Britain

4. Great Britain

5. Great Britain

Part 2 Northern Ireland

6. The Sex Discrimination (Northern Ireland) Order 1976 (S.I. 1976/1042 (N.I....

7. In Article 10A (gender reassignment: exception for genuine occupational qualification),...

8. In Article 10B (supplementary exceptions relating to gender reassignment), for...

9. In Article 12 (discrimination against contract workers), after paragraph (3C)...

10. In Article 14 (partnerships), after paragraph (3C) insert—

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Sweden’s parliament passes a law to make it easier for young people to legally change their gender

A view of the Swedish Parliament as lawmakers vote on the new gender identity law, in Stockholm, Wednesday, April 17, 2024. The Swedish parliament passed a law Wednesday lowering the age required for people to legally change their gender from 18 to 16. Young people under 18 will still need approval from a guardian, a doctor, and the National Board of Health and Welfare. The government of Prime Minister Ulf Kristersson has been split on the issue.(Jessica Gow/TT News Agency via AP)

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COPENHAGEN, Denmark (AP) — The Swedish parliament passed a law Wednesday lowering the age required for people to legally change their gender from 18 to 16. Those under 18 still need approval from a guardian, a doctor and the National Board of Health and Welfare.

No longer required is a gender dysphoria diagnosis, defined by medical professionals as psychological distress experienced by those whose gender expression does not match their gender identity.

Sweden joins a number of countries with similar laws including Denmark, Norway, Finland and Spain .

The vote in Sweden passed 234-94 with 21 lawmakers absent, following a debate that lasted for nearly six hours.

Sweden Democrats, the populist party with far-right roots that supports the government in parliament but is not part of the government, opposed the law.

Jimmie Akesson, leader of the Sweden Democrats, told reporters it was “deplorable that a proposal that clearly lacks the support of the population is so lightly voted through.”

But Johan Hultberg with the Moderates of Sweden’s conservative prime minister, Ulf Kristersson, called the outcome “gratifying.” Hultberg called it “a cautious but important reform for a vulnerable group. I’m glad we’re done with it.”

Kristersson’s center-right coalition had been split on the issue, with the Moderates and the Liberals largely supporting the law while the small Christian Democrats were against it.

Peter Sidlund Ponkala, chairman of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights, known by its Swedish acronym RFSL, called the law’s passage “a step in the right direction” and “a recognition for everyone who has been waiting for decades for a new law.”

Elias Fjellander, chairman of the organization’s youth branch, said it would make life better for its members. “Going forward, we are pushing to strengthen gender-affirming care, to introduce a third legal gender and to ban conversion attempts,” Fjellander said in a statement.

Last Friday, German lawmakers approved similar legislation , making it easier for transgender, intersex and nonbinary people to change their name and gender in official records directly at registry offices.

In the U.K., the Scottish parliament in 2022 passed a bill allowing people aged 16 or older to change their gender designation on identity documents by self-declaration. It was vetoed by the British government, a decision that Scotland’s highest civil court upheld in December . The legislation set Scotland apart from the rest of the U.K., where the minimum age is 18 and a medical diagnosis is required.

Danielle Laidley among advocates to welcome bid to scrap WA Gender Reassignment Board

Western Australians will no longer have to undergo medical or surgical reassignment in order to change their sex or gender, under the state government's proposed law reforms.

The state's Gender Reassignment Board, which manages applications to legally change a person's gender, would be abolished under the new laws.

Attorney-General John Quigley said the legislation would bring WA in line with the rest of Australia.

"This is not radical legislation … we're only bringing Western Australia out of the dark ages, up to a level of social reform that the rest of the country already respects and enjoys," he said.

Reforms will save lives, advocate says

Danielle Laidley is an AFL premiership winner, and one of the youngest senior coaches in the sport's history.

Laidley was outed as a trans woman by police, had her family turn their back on her, and survived the drugs she turned to as her life spiralled out of control.

"Today I can finally stand here, as a proud Western Australian and transgender woman," she said.

Laidley said the abolition of the Gender Reassignment Board was a step forward for WA.

"It was wrong for someone to sit there and tell me who I was. They haven't walked a mile in my shoes, they don't know how I feel," she said.

Transfolk of WA deputy chairperson Dylan Green said the reform was a significant step to creating a pathway for transgender and gender-diverse people to align legal documentation with their gender identity.

"This will improve the lives, and save the lives, of many trans and gender diverse people in Western Australia," he said.

However, Mr Green noted the state government's proposal did not meet all of the recommendations made by the state's Law Reform Commission in 2018.

"We will be making further recommendations to the government regarding the regulations for this proposed bill, and advocating for further law reform," he said.

"We've seen in other states … certain requirements for clinical evidence have been removed for adults over the age of 18, so they use the self-determination model.

"That is what is widely considered best practice."

More change to come

Under the new laws, adults who have received counselling would be able to apply for a sex-change through the Registry of Births, Deaths and Marriages.

Teenagers between 12 and 18-years-old would need the consent of both parents, and children under 12 would need approval from the WA Family Court.

The legislation also includes clauses prohibiting certain types of offenders from applying to change their gender.

"You don't want someone who, for example, has been convicted of a nasty, aggravated sexual offence, then changing gender so they can access women-only areas," Mr Quigley said.

The proposed bill would also make the sex descriptors "non-binary" and "indeterminate/intersex" available, alongside "male" and "female".

The reforms would not change the existing procedure for registering the sex of a newborn. It also contains a requirement for the legislation to be reviewed after three years.

Mr Quigley has flagged the proposed legislation is only the first tranche of a multitude of changes to remove barriers for, and improve the lives of, the LGBTQIA+ community.

The WA government is chasing further reforms, including the development of a new Equal Opportunity Act and banning conversion therapy practices, which the attorney-general said would have to wait until after the 2025 state election.

"The federal government has announced the Australian Law Reform Commission findings, and the Prime Minister has come out and said on some contentious areas he is hopeful of getting bipartisan support," Mr Quigley said.

"I don't want to come in from left field and upset the applecart."

Reform follows landmark UK review

The proposed law reform comes after a landmark investigation into gender-affirming care in England, known as the Cass Review.

It recommended significantly limiting the prescription of medications, known as puberty blockers, for people aged under 18.

Federal health minister Mark Butler described the review's findings as "significant" but said the clinical treatment of transgender children in Australia was very different than in the UK.

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