From the time she was 3 years old, Jessi* wanted to play with fairy costumes and pretend her blanket was long, flowy hair. Though assigned male at birth, it was clear to her mother, Beth Wall*, that Jessi felt like a girl. Almost 14 now, Jessi “has never wavered in who she is,” says Wall.
Around puberty, Jessi became increasingly distressed over masculinizing changes and ultimately received medication to halt them. “The day she got puberty blockers was the first time she slept through the night in years,” Wall remembers.
Now Jessi and her family have been plunged into fear as their state — which they declined to name to protect their privacy — has barred minors from receiving treatments that help align their body with their gender identity.
“There’s this dark cloud and fear hanging over us all the time,” says Wall. “We just want our child to be safe and happy, and this [legislation] is hurting every aspect of our lives.”
Across the United States, 23 states have adopted laws or policies that ban or severely limit gender-affirming care (GAC) for minors, and several others are eyeing the possibility. Experts estimate that the efforts could ultimately affect more than 144,000 young people.
In Idaho, a physician providing GAC to a minor could face up to 10 years in prison. In Missouri, a new law makes it easier for patients who change their minds after consenting to GAC to sue doctors and to win up to $1.5 million in damages. In Florida, parents who allow gender-affirming medical care can lose custody of their child.
Advocates of these laws make two main arguments: that research studies supporting GAC are inadequate and that adolescents are insufficiently mature to undertake such major changes.
“We need to understand what these emerging therapies actually may potentially do to our kids,” said Iowa Governor Kim Reynolds in April 2023 after signing her state’s legislation. “My heart goes out to them. … But I have to do what I believe right now is in the best interest of the kids.”
On their end, supporters of GAC point to research that it can be lifesaving for patients experiencing gender dysphoria — the painful disconnect between one’s physical traits and their sense of their gender identity.
“It’s terrible to know what people need to live authentically, what kids need to be healthy and sometimes even to save their lives, but not be able to provide that care.”
James Kroll*, MD
More than 20 U.S. medical groups support minors’ access to GAC, and many, including the Association of American Medical Colleges, have joined amicus briefs opposing the restrictions.
Nonetheless, the United States has seen a dramatic increase in legislation curtailing minors’ access to GAC. In 2018, two such laws were proposed. In 2021, 40. In 2023, the number reached 185. For example, Texas legislators introduced seven bills on the issue last year, including ones restricting insurance coverage for GAC and expanding civil liability for “genital mutilation of children.”
“There’s been an explosive growth in both the number and types of these bills,” says Jessica Fish, PhD, a University of Maryland researcher who studies how social factors influence the health of LGBTQ+ youth. “Now it looks like states are already on track in 2024 to surpass last year.”
Meanwhile, providers are working to help young transgender patients as best they can. Often, they do so while grappling with their own frustrations at legislative restrictions on patient and parental autonomy and provider expertise.
“It’s terrible to know what people need to live authentically, what kids need to be healthy and sometimes even to save their lives, but not be able to provide that care,” says James Kroll*, MD, a family physician at a teaching hospital in a Midwestern state. “It’s just awful.”
Losing access to gender-affirming care
GAC for youth has multiple components, including psychological and behavioral care focused on such concerns as how to dress and other aspects of presenting one’s gender identity.
State laws mostly take aim at gender-affirming medical treatments. Such care for young people often begins at puberty with medications — the effects of which are reversible — that halt changes like a deepening voice. After these puberty blockers, patients may receive hormones — some effects of which are not reversible — that induce traits aligned with the patient’s gender identity. GAC surgery among youth is rare, experts say.
Many of those who oppose GAC for minors argue that these individuals are not yet mature enough to make such major decisions. A 2021 study found that 11% of participants who pursued gender affirmation later detransitioned back to their birth-assigned gender due to an external factor (such as parental pressure) and 2% detransitioned due to an internal factor (such as uncertainty around their gender). Opponents also point to some European countries that once were at the forefront of GAC but now are tightening eligibility for it.
Following evidence-based guidelines can help ensure that medical care aligns appropriately with patients’ needs, doctors say.
Guidelines and policies from the Endocrine Society, the American Academy of Pediatrics, and the World Professional Association for Transgender Health lay out how and when GAC should be provided. The recommendations include that young people seeking GAC should undergo thorough assessments to ensure that they show sustained patterns of gender dysphoria. Youth also must have the emotional and cognitive ability to provide informed consent and if they have not reached their state’s age of legal consent, their parents or guardians must consent.
Providers who offer GAC point to evidence that gender dysphoria can be dangerous. In fact, 9 out of 10 adults who wanted puberty blockers when they were younger but didn’t receive them reported contemplating suicide. And transgender youth who received puberty blockers or gender-affirming hormones were 73% less likely to consider suicide than those who did not.
Wall saw dramatic changes in Jessi after she began GAC. “For two years, she was experiencing tremendous anxiety. My super-bubbly, happy kid had disappeared,” says Wall. “After transitioning, that child was back.”
But why not just wait until turning 18 to begin medication, as recent laws generally require?
For one, waiting comes with physical ramifications, doctors say. “If you go through male puberty, for example, testosterone does a lot that is difficult to undo,” explains Jennifer Scott*, MD, a Midwestern physician who provides transgender care. “It’s hard to take away an Adam’s apple once it develops.”
Waiting can have psychological fallout as well.
“If you feel your body is betraying you, it interferes with your everyday life. It makes it hard to get to school, do homework, socialize. Your emotional healing is delayed,” says Deanna Adkins, MD, an associate professor of pediatrics at Duke University School of Medicine in Durham, North Carolina, and a Duke Health GAC provider. (Her state passed legislation restricting GAC care for minors in 2023.)
“The legislation has brought into daily conversations … some very private aspects of my child’s life. These are conversations about whether she should be able to continue to exist as the person she is.”
Beth Wall*
For patients who start hormone treatment but then must stop after legislation passes, it can be highly distressing to see desired changes begin slipping away and unwanted, permanent ones develop, Adkins explains.
In states that pass anti-GAC laws, says Wall, the only options for families like hers are detransitioning or going out of state for care.
Moving would involve great challenges, including the risk of upending her daughter’s social life. “Jessi has tons of friends here. It would be hard to replace that where kids may have a different sense of her based on misinformation and disinformation about transgender people,” Wall says.
But staying is hard as well. “The legislation has brought into daily conversations in my state some very private aspects of my child’s life. These are conversations about whether she should be able to continue to exist as the person she is.”
The impact on providers
Legislation restricting GAC can have serious consequences for providers as well, including being deemed a felon in five states.
And such laws are unnecessary, some physicians argue, since mechanisms — including malpractice lawsuits and review by state medical licensing boards — already exist to sanction doctors who fail to meet accepted standards of care. “Unless states are going to legislate every aspect of medicine, I don’t see why we need laws specifically around this,” says Toby Smith*, MD, who provides GAC in a state that restricts it.
The laws also can be confusing and can require extensive — and rapid — contact with institutions’ lawyers to understand and avoid breaching them.
Even if a proposed piece of legislation doesn’t pass, its initiation can throw physicians into a flurry of preparatory activity.
Part of the work entails determining how to communicate with patients and the public. In some states, that includes crafting careful messaging so as to not risk the ire of legislators responsible for funding — or not funding — state hospital systems.
Scott recalls the painful process of telling families about care that would end. “We had to have these conversations over and over. Parents and kids were brought to tears. Staff were brought to tears,” she says.
“It was terrifying to think people in my building could have something happen to them because of the treatment we provide.”
Deanna Adkins, MD
Duke Health
The laws also bring fear into doctors’ offices. For one, there is worry over “secret shoppers,” people posing as families seeking care who instead aim to catch doctors they think are breaking the law.
The fear extends beyond landing in legal trouble, says Adkins.
“After the legislation was proposed, we immediately saw social media attacks against providers... Some groups put up billboards with doctors’ faces on them.”
“We also had some people using threatening language toward our clinic,” Adkins adds. “It was terrifying to think people in my building could have something happen to them because of the treatment we provide.”
Working to support patients
In states that restrict or ban GAC for minors, providers have been working to help patients as best they can.
At Scott’s clinic, that meant calling roughly 300 people when her state passed legislation in 2023. “We contacted every patient so they wouldn’t have to make a sometimes four-hour drive just to be told all we could do is provide information about out-of-state options,” she says.
At Adkins’ clinic, staff rushed to add appointments for new patients in the time — seven weeks — between the law’s passage and its effective date so as to leverage its “grandfather” clause allowing patients already receiving GAC to continue doing so. Because the legislation prohibited Medicaid coverage of GAC for minors, staff also helped some grandfathered patients apply for nonprofit grants and hospital charity care.
Another goal has been expediting out-of-state treatment for patients. At Duke Health, staff have been performing such preliminary steps as the physical and psychological assessments necessary for GAC, which are not illegal.
But connecting patients to out-of-state care isn’t simple. Waitlists are sometimes months or even years long. And in eight states, making such connections could be deemed aiding and abetting a crime, according to a Kaiser Family Foundation analysis.
Providers are also working to help those patients who are required to ease off GAC medication. Scott provides an example: “When someone who identifies as male ceases puberty blockers, their menstrual periods will start again, which can cause a lot of dysphoria. So we discuss birth control and other ways to stop periods.”
But sometimes all a doctor can do is explain what to expect as prescribed hormones subside. “For those patients, it’s just a matter of waiting anxiously until they turn 18,” Scott says.
Some providers worry that even that option will wither as GAC opponents work to expand restrictions. Bills prohibiting GAC medical care for young people up to age 26 have been introduced in at least four states in the past year.
As all this unfolds, supporters of GAC are pushing back in court. Plaintiffs in 16 states have challenged laws and policies limiting GAC for minors with some success. The Biden administration also has asked the Supreme Court to weigh in.
Meanwhile, the temptation to move to a more “friendly” state is real, but many providers, including Kroll, say they’ll stay as long as their young patients need them.
“Whenever you’re doing any kind of care that is under political attack, there’s always a risk-benefit balance,” he says. “Leaving a hostile place would be easier, but I want to try to do as much good as possible for as many of the people here who need me.”
*Several individuals in this article requested anonymity to protect themselves, their families, or their institutions from personal or political retribution.
