gender reassignment on minors

Young Children Do Not Receive Medical Gender Transition Treatment

By Kate Yandell

Posted on May 22, 2023

SciCheck Digest

Families seeking information from a health care provider about a young child’s gender identity may have their questions answered or receive counseling. Some posts share a misleading claim that toddlers are being “transitioned.” To be clear, prepubescent children are not offered transition surgery or drugs.

Some children  identify  with a gender that does not match their sex assigned at birth. These children are referred to as transgender, gender-diverse or gender-expansive. Doctors will listen to children and their family members, offer information, and in some cases connect them with mental health care, if needed.

But for children who have not yet started puberty, there are  no recommended  drugs, surgeries or other gender-transition treatments.

Recent social media  posts   shared  the misleading  claim  that medical institutions in North Carolina are “transitioning toddlers,” which they called an “experimental treatment.” The posts referenced a  blog post  published by the Education First Alliance, a conservative nonprofit in North Carolina that says  many schools are engaging in “ideological indoctrination” of children and need to be reformed.

The group has advocated the passage of a North Carolina bill  to restrict medical gender-transition treatment before age 18. There are now  18 states  that have taken action to restrict  medical transition treatments  for  minors .

A widely shared  article  from the Epoch Times citing the blog post bore the false headline: “‘Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges.” The Epoch Times has a history of publishing misleading or false claims. The article on transgender toddlers then disappeared from the website, and the Epoch Times published a new  article  clarifying that young children are not receiving hormone blockers, cross-sex hormones or surgery. 

Representatives from all three North Carolina institutions referenced in the social media posts told us via emailed statements that they do not offer surgeries or other transition treatments to toddlers.

East Carolina University, May 5: ECU Health does not offer gender affirming surgery to minors nor does the health system offer gender affirming transition care to toddlers.

ECU Health elaborated that it does not offer puberty blockers and only offers hormone therapy after puberty “in limited cases,” as recommended in national guidelines and with parental or guardian consent. It also said that it offers interdisciplinary gender-affirming primary care for LGBTQ+ patients, including access to services such as mental health care, nutrition and social work.

“These primary care services are available to any LGBTQ+ patient who needs care. ECU Health does not provide gender-related care to patients 2 to 4 years old or any toddler period,” ECU said.

University of North Carolina, May 12: To be clear: UNC Health does not offer any gender-transitioning care for toddlers. We do not perform any gender care surgical procedures or medical interventions on toddlers. Also, we are not conducting any gender care research or clinical trials involving children. If a toddler’s parent(s) has concerns or questions about their child’s gender, a primary care provider would certainly listen to them, but would never recommend gender treatment for a toddler. Gender surgery can be performed on anyone 18 years old or older .

Duke Health, May 12: Duke Health has provided high-quality, compassionate, and evidence-based gender care to both adolescents and adults for many years. Care decisions are made by patients, families and their providers and are both age-appropriate and adherent to national and international guidelines. Under these professional guidelines and in accordance with accepted medical standards, hormone therapies are explicitly not provided to children prior to puberty and gender-affirming surgeries are, except in exceedingly rare circumstances, only performed after age 18.

Duke and UNC both called the claims that they offer gender-transition care to toddlers false, and ECU referred to the “intentional spreading of dangerous misinformation online.”

Nor do other medical institutions offer gender-affirming drug treatment or surgery to toddlers, clinical psychologist  Christy Olezeski , director of the Yale Pediatric Gender Program, told us, although some may offer support to families of young children or connect them with mental health care. 

The Education First Alliance post also states that a doctor “can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.” But simply playing with a certain toy would not meet the criteria for a diagnosis of gender dysphoria, according to the medical diagnostic manual used by health professionals.

“With all kids, we want them to feel comfortable and confident in who they are. We want them to feel comfortable and confident in how they like to express themselves. We want them to be safe,” Olezeski said. “So all of these tenets are taken into consideration when providing care for children. There is no medical care that happens prior to puberty.”

Medical Transition Starts During Adolescence or Later 

The Education First Alliance blog post does not clearly state what it means when it says North Carolina institutions are “transitioning toddlers.” It refers to treatment and hormone therapy without clarifying the age at which it is offered. 

Only in the final section of the piece does it include a quote from a doctor correctly stating that children are not offered surgery or drugs before puberty.

To spell out the reality of the situation: The North Carolina institutions are not providing surgeries or hormone therapy to prepubescent children, nor is this standard practice in any part of the country.

Programs and physicians will have different policies, but widely referenced guidance from the  World Professional Association for Transgender Health  and the  Endocrine Society  lays out recommended care at different ages. 

Drugs that suppress puberty are the first medical treatment that may be offered to a transgender minor, the guidelines say. Children may be offered drugs to suppress puberty beginning when breast buds appear or testicles increase to a certain volume, typically happening between ages 8 to 13 or 9 to 14, respectively.

Generally, someone may start gender-affirming hormone therapy in early adolescence or later, the American Academy for Pediatrics  explains . The Endocrine Society says that adolescents typically have the mental capacity to participate in making an informed decision about gender-affirming hormone therapy by age 16.

Older adolescents who want flat chests may sometimes be able to get surgery to remove their breasts, also known as top surgery, Olezeski said. They sometimes desire to do this before college. Guidelines  do not offer  a  specific age  during adolescence when this type of surgery may be appropriate. Instead, they explain how a care team can assess adolescents on a case-by-case basis.

A previous  version  of the WPATH guidelines did not recommend genital surgery until adulthood, but the most recent version, published in September 2022, is  less specific  about an age limit. Rather, it explains various criteria to determine whether someone who desires surgery should be offered it, including a person’s emotional and cognitive maturity level and whether they have been on hormone therapy for at least a year.

The Endocrine Society similarly offers criteria for when someone might be ready for genital surgery, but specifies that surgeries involving removing the testicles, ovaries or uterus should not happen before age 18.

“Typically any sort of genital-affirming surgeries still are happening at 18 or later,” Olezeski said.

There are no comprehensive statistics on the number of gender-affirming surgeries performed in the U.S., but according to an insurance claims  analysis  from Reuters and Komodo Health Inc., 776 minors with a diagnosis of gender dysphoria had breast removal surgeries and 56 had genital surgeries from 2019 to 2021.

Research Shows Benefits of Affirming Gender Identity

Young children do not get medical transition treatment, but they do have feelings about their gender and can benefit from support from those around them. “Children start to have a sense of their own gender identity between the ages of 2 1/2 to 3 years old,” Olezeski said.

Programs vary in what age groups they serve, she said, but some do support families of preschool-aged children by answering questions or providing mental health care.

Transgender children are at increased risk of some mental health problems, including anxiety and depression. According to the WPATH guidelines, affirming a child’s gender through day-to-day changes — also known as social transition — may have a positive impact on a child’s mental health. Social transition “may look different for every individual,” Olezeski said. Changes could include going by a different name or pronouns or altering one’s attire or hair style.

Two studies of socially transitioned children — including one with kids as young as 3 — have found minimal or no difference in anxiety and depression compared with non-transgender siblings or other children of similar ages.

“Research substantiates that children who are prepubertal and assert an identity of [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance,” the AAP  guidelines  say, adding that differences in how children identify and express their gender are normal.

Social transitions largely take place outside of medical institutions, led by the child and supported by their family members and others around them. However, a family with questions about their child’s gender or social transition may be able to get information from their pediatrician or another medical provider, Olezeski said.

Although not available everywhere, specialized programs may be particularly prepared to offer care to a gender-diverse child and their family, she said. A child may get a referral to one of these programs from a pediatrician, another specialty physician, a mental health care professional or their school, or a parent may seek out one of these programs.

“We have created a space where parents can come with their youth when they’re young to ask questions about how to best support their child: what to do if they have questions, how to get support, what do we know about the best research in terms of how to allow kids space to explore their identity, to explore how they like to express themselves, and then if they do identify as trans or nonbinary, how to support the parents and the youth in that,” Olezeski said of specialized programs. Parents benefit from the support, and then the children also benefit from support from their parents. 

WPATH  says  that the child should be the one to initiate a social transition by expressing a “strong desire or need” for it after consistently articulating an identity that does not match their sex assigned at birth. A health care provider can then help the family explore benefits and risks. A child simply playing with certain toys, dressing a certain way or enjoying certain activities is not a sign they would benefit from a social transition, the guidelines state.

Previously, assertions children made about their gender were seen as “possibly true” and support was often withheld until an age when identity was believed to become fixed, the AAP guidelines explain. But “more robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the guidelines say.

Mental Health Care Benefits

A gender-diverse child or their family members may benefit from a referral to a psychologist or other mental health professional. However, being transgender or gender-diverse is not in itself a mental health disorder, according to the  American Psychological Association ,  WPATH and other expert groups . These organizations also note that people who are transgender or gender-diverse do not all experience mental health problems or distress about their gender. 

Psychological therapy is not meant to change a child’s gender identity, the WPATH guidelines  say . 

The form of therapy a child or a family might receive will depend on their particular needs, Olezeski said. For instance, a young child might receive play-based therapy, since play is how children “work out different things in their life,” she said. A parent might work on strategies to better support their child.

One mental health diagnosis that some gender-diverse people may receive is  gender dysphoria . There is  disagreement  about how useful such a diagnosis is, and receiving such a diagnosis does not necessarily mean someone will decide to undergo a transition, whether social or medical.

UNC Health told us in an email that a gender dysphoria diagnosis “is rarely used” for children.

Very few gender-expansive kids have dysphoria, the spokesperson said. “ Gender expansion in childhood is not Gender Dysphoria ,” UNC added, attributing the explanation to psychiatric staff (emphasis is UNC’s). “The psychiatric team’s goal is to provide good mental health care and manage safety—this means trying to protect against abuse and bullying and to support families.”

Social media posts incorrectly claim that toddlers are being diagnosed with gender dysphoria based on what toys they play with. One post  said : “Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!!”

There are separate criteria for diagnosing gender dysphoria in adults and adolescents versus children, according to the Diagnostic and Statistical Manual of Mental Disorders. For children to receive this diagnosis, they must meet six of eight criteria for a six-month period and experience “clinically significant distress” or impairment in functioning, according to the diagnostic manual. 

A “strong preference for the toys, games or activities stereotypically used or engaged in by the other gender” is one criterion, but children must also meet other criteria, and expressing a strong desire to be another gender or insisting that they are another gender is required.

“People liking to play with different things or liking to wear a diverse set of clothes does not mean that somebody has gender dysphoria,” Olezeski said. “That just means that kids have a breadth of things that they can play with and ways that they can act and things that they can wear . ”

Editor’s note: SciCheck’s articles providing accurate health information and correcting health misinformation are made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation.

Rafferty, Jason. “ Gender-Diverse & Transgender Children .” HealthyChildren.org. Updated 8 Jun 2022.

Coleman, E. et al. “ Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 .” International Journal of Transgender Health. 15 Sep 2022.

Rachmuth, Sloan. “ Transgender Toddlers Treated at Duke, UNC, and ECU .” Education First Alliance. 1 May 2023.

North Carolina General Assembly. “ Senate Bill 639, Youth Health Protection Act .” (as introduced 5 Apr 2023).

Putka, Sophie et al. “ These States Have Banned Youth Gender-Affirming Care .” Medpage Today. Updated 17 May 2023.

Davis, Elliott Jr. “ States That Have Restricted Gender-Affirming Care for Trans Youth in 2023 .” U.S. News & World Report. Updated 17 May 2023.

Montgomery, David and Goodman, J. David. “ Texas Legislature Bans Transgender Medical Care for Children .” New York Times. 17 May 2023.

Ji, Sayer. ‘ Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges .” Epoch Times. Internet Archive, Wayback Machine. Archived 6 May 2023.

McDonald, Jessica. “ COVID-19 Vaccines Reduce, Not Increase, Risk of Stillbirth .” FactCheck.org. 9 Nov 2022.

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Spencer, Saranac Hale. “ Social Media Posts Misrepresent FDA’s COVID-19 Vaccine Safety Research .” FactCheck.org. 23 Dec 2022.

Jaramillo, Catalina. “ WHO ‘Pandemic Treaty’ Draft Reaffirms Nations’ Sovereignty to Dictate Health Policy .” FactCheck.org. 2 Mar 2023.

McCormick Sanchez, Darlene. “ IN-DEPTH: North Carolina Medical Schools See Children as Young as Toddlers for Gender Dysphoria .” The Epoch Times. 8 May 2023.

ECU health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

UNC Health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

Duke Health spokesperson. Email with FactCheck.org. 12 May 2023.

Olezeski, Christy. Interview with FactCheck.org. 16 May 2023.

Hembree, Wylie C. et al. “ Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline .” The Journal of Clinical Endocrinology and Metabolism. 1 Nov 2017.

Emmanuel, Mickey and Bokor, Brooke R. “ Tanner Stages .” StatPearls. Updated 11 Dec 2022.

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Coleman, E. et al. “ Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 .” International Journal of Transgenderism. 27 Aug 2012.

Durwood, Lily et al. “ Mental Health and Self-Worth in Socially Transitioned Transgender Youth .” Journal of the American Academy of Child and Adolescent Psychiatry. 27 Nov 2016.

Olson, Kristina R. et al. “ Mental Health of Transgender Children Who Are Supported in Their Identities .” Pediatrics. 26 Feb 2016.

“ Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression .” American Psychological Association website. 9 Mar 2023.

“ What is Gender Dysphoria ?” American Psychiatric Association website. Updated Aug 2022.

Vanessa Marie | Truth Seeker (indivisible.mama). “ Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!! … ” Instagram. 7 May 2023.

Does Your Hospital Trans Kids? Find Out Here

Media Mention

Nearly 14,000 Minors Underwent Sex-Change Procedures in Recent Years, According to New Watchdog Database

• October 8, 2024
• National Review

A medical watchdog organization released groundbreaking data on Tuesday revealing the number of total child sex-change interventions that have been administered in the U.S. in recent years, as well as the locations where the procedures are taking place.

Do No Harm, a nonprofit that combats child gender transitions and discrimination in medicine, constructed a database quantifying the extent to which American children are receiving gender-transition procedures.

From January 2019 to December 2023, 13,994 minor patients received gender-transition treatments, with 5,747 undergoing sex-change surgeries and 8,579 getting hormones and puberty blockers, according to Do No Harm’s  database . A majority of the body-modification procedures.

Read more on National Review .

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Database: More than 13,000 gender reassignment procedures on minors between 2019-23

(The Center Square) – Sex reassignment procedures and surgeries on children have gained national prominence in recent years, and half of U.S. states now have laws passed either restricting or banning them.

Newly released data provided by the nonprofit Do No Harm indicates that the number of procedures overall has increased since at least 2019.

While many of those procedures from 2019 through 2023 occurred in states known for championing the right of juveniles to have irreversible medical procedures done even without parental knowledge or consent, such as California and Washington, some states that have since placed restrictions or outright bans on the procedures also have some of the highest numbers.

According to Do No Harm, between 2019 and 2023, there were at least 13,394 gender reassignment procedures nationwide on individuals 17.5 years old or younger, with the youngest 7 years old.

“Procedures” are defined as either the use of puberty or hormone blockers, or gender reassignment surgeries such as mastectomies and penile reconstruction. The organization reports that of those, there were 4,160 breast removal procedures on minors and 660 phalloplasty procedures.

Do No Harm Director of Programs Michelle Havrilla said in a statement that "body modification surgeries such as so-called vaginoplasties and phalloplasties are irreversible. The majority of these patients will end up with life-long complications related to these procedures."

Phalloplasty is a complex surgery that involves constructing or reconstructing a penis using other skin parts, according to John Hopkins Medicine, while in vaginoplasties, "tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva."

"Phalloplasties carry uncertain long-term health risks; these may include fistulas, chronic infection, the need for a colostomy, atrophy, and complete loss of sensation, sexual or otherwise," Havrilla said.

Do No Harm is a nonprofit group of physicians and other medical professionals that gets its name from the Hippocratic oath: "First, do no harm." According to its website, Do No Harm is "fighting to curtail the unscientific and individually harmful practice of so-called 'gender affirming care'" for children.

“'Gender-affirming care' is based on the dangerous premise that any child who has distress that he or she thinks is related to their sex should automatically be treated with social transition to the sex of their choice followed by hormonal interventions and then possibly surgery to remove healthy body parts," it says. "Underlying mental health problems are usually not addressed."

According to Do No Harm's data, 2022 was the highest year for every state except for one when it came to the number of puberty or hormone blockers prescribed; the outlier was Alabama, which had 10 in both 2022 and 2023.

When it came to the total number of transgender surgeries on minors, 21 out of 50 states had increases from 2022 to 2023.

Surgeries in California – which recorded the most gender reassignment procedures during the time period – dropped from 344 to 266 between 2022-23, while the number in Washington fell from 90 to 67 during the same time period.

Nationwide, 42 states had higher puberty or hormone blocker prescriptions given to minors in 2023 than 2019, while 31 states had a higher number of surgeries in 2023 compared to 2019.

Do No Harm says its data was obtained through a variety of sources including “claims clearinghouses, data aggregators, payors, health systems, CMS, and multiple open data sources. The final product includes data from commercial insurance, Medicaid, Medicare, and VA claims.” Do No Harm says it was conservative when counting the number of procedures on children; if there was any doubt whether a procedure involved sex reassignment on a minor, it was excluded.

Of those procedures involving a minor, almost 40% were performed in just four states – California, New York, Washington, and Ohio. California had the highest number of total procedures at 2,083.

California was not among the top 10 states for procedures per capita, however. While Ohio ranked fourth in total procedures (1,020), it also ranked seventh in procedures per capita, at one per 11,568 residents. California’s per capita was one procedure per 18,981 residents, which was less than New Hampshire’s one per 10,678 residents.

Washington ranked third for both total procedures performed (1,082) and the number of procedures per capita, at one procedure per 7,121 residents.

The state with the highest gender reassignment procedure rate per capita was Oregon, which had 899 procedures but with a population of 4.2 million constituted one procedure per 4,713 residents. Hawaii, with a population of 1.46 million and 15 procedures, had the lowest rate at one procedure per 291,054 residents.

Though it ranked eighth for the number of total procedures (718), Massachusetts medical centers billed the third most for gender reassignment procedures on minors at $10 million. That's compared to $7 million in total charges in Washington, which had 364 more procedures. New York billed $19 million, while California medical providers billed the most at $29 million.

Although states such as Montana and Alabama enacted bans on those procedures in 2022, and Arkansas in 2021, Do No Harm’s data shows that all three states continued to have medical providers billing for these procedures into 2023.

Ohio now has a ban on gender reassignment surgery and hormone blockers. That law passed in January, beyond the scope of Do No Harm’s data timeframe. The law was upheld by a judge in August. Before the law went into effect, hospitals in Ohio treated 1,004 minors, including 224 surgeries.

Do No Harm also published a new database listing the hospitals where these procedures were conducted the most. According to Do No Harm's database, called "Does my hospital transition kids?", the hospitals where the most sex reassignment procedures and surgeries on children were conducted were at the Children's Hospital of Philadelphia, Connecticut Children's Medical Center, Children's Minnesota, Seattle Children's, and Children's Hospital Los Angeles.

The database, which is searchable by state, lists 225 hospitals where such procedures have occurred.

When Transgender Kids Transition, Medical Risks are Both Known and Unknown

The last couple of years have seen burgeoning awareness in society of what it means to be transgender as an adult. But now doctors, like those at Ann and Robert H. Lurie Children’s Hospital of Chicago, are helping children who identify as transgender negotiate their journey into adulthood.

For earlier generations of transgender people, the only way to transition physically was through surgery or taking hormones as adults. However, new medical options are allowing transgender children to start the process of transitioning at younger ages.

But doctors tread carefully, navigating medical interventions that carry risks that are both known and unknown.

PUTTING A PAUSE ON PUBERTY

When someone makes the decision to transition, part of that process can be social — choosing a new name, changing pronouns, wearing different clothes — and part of it can be medical.

One of the more recent medical developments is the use of puberty blockers to treat children who are transgender or gender non-conforming. The medications, which suppress the body’s production of estrogen or testosterone, essentially pause the changes that would occur during puberty.

“That’s really what these pubertal blockers do,” Dr. Rob Garofalo told FRONTLINE. Garofalo is the director of the Lurie Children’s Hospital’s Gender and Sex Development Program. “They allow these families the opportunity to hit a pause button, to prevent natal puberty … until we know that that’s either the right or the wrong direction for their particular child.”

Doctors who use puberty blockers say they allow children who experience gender dysphoria — the feeling that they’re in the wrong body — the time and space to explore and settle on their gender identity. What makes treatment tricky is that there is no test that can tell whether a child experiencing distress about their gender will grow up to be transgender. The handful of studies that do exist suggest that gender dysphoria persists in a minority of children, but they involved very few children and were done mostly abroad.

Puberty blockers have been tested and used for children who start puberty very young — if their bodies start to change before the age of eight or nine. Dr. Courtney Finlayson, a pediatric endocrinologist at Lurie Children’s Hospital, said, “We have a lot of experience in pediatric endocrinology using pubertal blockers. And from all the evidence we have they are generally a very safe medication.”

But their use in treating transgender children is a relatively new practice, first prescribed in the United States by the Gender Management Service at Boston Children’s Hospital in 2007, and recommended in the Endocrine Society’s guidelines for the treatment of transgender people in 2009.

Doctors say the benefit of using puberty blockers is that they block hormone-induced biological changes, such as vocal chord changes, the development of breast tissue or changes in facial structure, that are irreversible and can be especially distressing to children who are gender-non conforming or transgender.

“One of the challenges that’s been faced in the past is that treatment of the transgender population really didn’t start until they were either at least older adolescents or adults,” said Finlayson. “And by that time they’ve had all of the pubertal and physical changes that go along with their … natal sex.”

With the use of puberty blockers, “we’re really starting to some extent from a little bit more of a blank slate,” Finlayson explained. “We don’t have to be erasing or trying to get rid of all these other changes that occurred that they don’t want.”

However, the use of puberty blockers to treat transgender children is what’s considered an “off label” use of the medication — something that hasn’t been approved by the Food and Drug Administration. And doctors say their biggest concern is about how long children stay on the medication, because there isn’t enough research into the effects of stalling puberty at the age when children normally go through it.

The Endocrine Society’s guidelines suggest starting puberty blockers for transgender children when they hit a stage of development known as Tanner stage 2 — usually around 10 or 11 years old for a girl and 11 or 12 years old for a boy. The same guidelines suggest giving cross sex hormones — estrogen for transgender girls and testosterone for transgender boys — at age 16. However, doctors caution that estrogen and testosterone, the hormones that are blocked by these medications, also play a role in a child’s neurological development and bone growth.

“We do know that there is some decrease in bone density during treatment with pubertal suppression,” Finlayson said, adding that initial studies have shown that starting estrogen and testosterone can help regain the bone density. What Finlayson said there isn’t enough research on is whether someone who was on puberty blockers will regain all their bone strength, or if they might be at risk for osteoporosis in the future.

Another area where doctors say there isn’t enough research is the impact that suppressing puberty has on brain development.

“The bottom line is we don’t really know how sex hormones impact any adolescent’s brain development,” Dr. Lisa Simons, a pediatrician at Lurie Children’s, told FRONTLINE. “We know that there’s a lot of brain development between childhood and adulthood, but it’s not clear what’s behind that.” What’s lacking, she said, are specific studies that look at the neurocognitive effects of puberty blockers.

“I wouldn’t use [puberty blockers] if I didn’t think that they were safe, or that the benefits didn’t outweigh the potential risks,” Finlayson said. “But we always have this conversation with families before we start.”

STARTING HORMONES

The stakes are higher for children who want to continue physically transitioning by taking the hormones of their desired gender. Doctors grapple with when to start cross-sex hormones, and they say it really depends on the child’s readiness and stability in their gender identity.

While the Endocrine Society’s guidelines suggest 16, more and more children are starting hormones at 13 or 14 once their doctors, therapists and families have agreed that they are mentally and emotionally prepared. The shift is because of the concerns over the impact that delaying puberty for too long can have on development, physically, emotionally and socially.

The physical changes that hormones bring about are irreversible, making the decision more weighty than taking puberty blockers. Some of the known side effects of hormones include things that might sound familiar: acne and changes in mood. Patients are also warned that they may be at higher risk for heart disease or diabetes later in life. The risk of blood clots increases for those who start estrogen. And the risk for cancer is an unknown, but it is included in the warnings doctors give their patients.

Another potential dilemma facing transgender children, their families and their doctors is this: Taking cross hormones can reduce fertility. And there isn’t enough research to find out of it is reversible or not. So when children make the decision to start taking hormones, they have to consider whether they ever want to have biological children.

“I think it’s really important to talk to these children and families about fertility,” Finlayson says. “I do worry that at that stage in life many of them may not be able to realize how important that would be to them someday.”

It’s an ethical question that each family has to deal with in their own way, because if a child goes from taking puberty blockers to taking hormones, they may no longer have viable eggs or sperm at the age when they decide they would like to have children. They do have the option to start their puberty and delay their treatment in order to store eggs or sperm, but some of them may not want to.

While transgender adults have taken hormones sometimes for years, the generation growing up now is among the first to start taking hormones so young. Since most people who start hormones take them for life, doctors say there also isn’t enough research into the long-term impact of taking estrogen or testosterone for what could end up being 50 to 70 years.

“There are so many unanswered questions around the long-term consequences, and whether your health risk profile really becomes that of a male or female,” Garofalo says. “If we start testosterone today, will you have the cardiac risk profile of a male or female as you grow older? Will you develop breast cancer because we’re administering estrogen?

“I think those are the unanswered questions that really trouble me, and can only be answered with long-term follow-up studies.”

THE COST OF TRANSITIONING

Most of these treatments are still very expensive and often out of reach for people without the help of insurance. The cost of puberty blockers is approximately $1,200 per month for injections and can range from $4,500 to $18,000 for an implant. The least expensive form of estrogen, a pill, can cost anywhere between $4 to $30 a month, according to Simons, while testosterone can be anywhere between $20 to $200 a vial.

“What we’re seeing in the clinic is that whether or not specific insurance plans cover medication or not is completely arbitrary,” Simons said. “It really can’t be predicted very easily.”

“We almost always just expect a denial,” she said.

“Though it is not the only treatment, doctor-supervised medical transition is critically important to aid people in the treatment of gender dysphoria,” Vincent Paolo Villano, the director of communications at the National Center for Transgender Equality, told FRONTLINE. “Access to medical transition is often unobtainable due to cost and insurance discrimination.”

“Transgender people experience twice the rate of unemployment as non-transgender people, which means they often lack insurance to gain access to health care, period,” Villano said. “And even for trans people with insurance, health plans often outright ban coverage of transition-related care, forcing transgender people to pay outrageous out-of-pocket expenses for medically-necessary procedures that are covered without question for non-transgender people.”

But the trend might be changing, with some insurance companies starting to cover the cost of transitioning. The team at Lurie Children’s Hospital says it has seen several cases in recent months that did not require appeals, or covered the medication after the first appeal.

Ultimately, the doctors working in clinics like the one at Lurie Children’s hope to spare transgender children some of the anguish and societal isolation that earlier generations of transgender people went through. But they too would like the answers to the unknown consequences of these medications.

“The stakes are super high, and we don’t have all the answers,” Garofalo says. “Hopefully, there’s going to be more research and some of those unanswered questions, hopefully, will begin to be answered.”

Priyanka Boghani , Digital Editor , FRONTLINE

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Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions

Lindsey Dawson and Jennifer Kates

Last updated on November 26, 2024

states have enacted laws/ policies limiting youth access to GAC

of trans youth (ages 13-17) live in a state that has enacted a law/policy limiting access to GAC

states are facing lawsuits challenging their laws/policies limiting youth access to GAC

states impose professional or legal penalties on health care practitioners providing minors with GAC

State laws and policies prohibiting or restricting minor access to gender affirming care have proliferated in recent years. The first state to pass such a law was Arkansas in 2021. By January 2024, that number increased more than five-fold, with states having passed such laws/policies. Most are being challenged in court, though the majority remain in effect.

This tracker provides an overview of these laws/policies and any associated litigation by state, identifying which groups of people are impacted in addition to minors (e.g. providers, parents, etc.), the types of penalties providers face (i.e. professional or felony), the status of legal challenges, and other key information.

Learn more in this short analysis assessing the policy landscape as of January 24, 2024: The Proliferation of State Actions Limiting Youth Access to Gender Affirming Care

What is Gender Affirming Care (GAC)?

Gender-affirming care is a model of care which includes a spectrum of “medical, surgical, mental health, and non-medical services for transgender and nonbinary people” aimed at affirming and supporting an individual’s gender identity. Gender-affirming care is a model of care which includes a spectrum of “medical, surgical, mental health, and non-medical services for transgender and nonbinary people” aimed at affirming and supporting an individual’s gender identity. Gender affirmation is highly individualized . Not all trans people seek the same types of gender affirming care or services and some people choose not to use medical services as a part of their transition.

Database: More than 13,000 gender reassignment procedures on minors between 2019 and 2023

40% were performed in just four states: california, new york, washington and ohio.

Sex reassignment procedures and surgeries on children have gained national prominence in recent years, and half of U.S. states now have laws passed either restricting or banning them.

Newly released data provided by the nonprofit Do No Harm indicates that the number of procedures overall has increased since at least 2019.

While many of those procedures from 2019 through 2023 occurred in states known for championing the right of juveniles to have irreversible medical procedures done even without parental knowledge or consent, such as California and Washington, some states that have since placed restrictions or outright bans on the procedures also have some of the highest numbers.

According to Do No Harm, between 2019 and 2023, there were at least 13,394 gender reassignment procedures nationwide on individuals 17.5 years old or younger, with the youngest 7 years old. 

“Procedures” are defined as either the use of puberty or hormone blockers, or gender reassignment surgeries such as mastectomies and penile reconstruction. The organization reports that of those, there were 4,160 breast removal procedures on minors and 660 phalloplasty procedures.

Do No Harm Director of Programs Michelle Havrilla said in a statement that "body modification surgeries such as so-called vaginoplasties and phalloplasties are irreversible. The majority of these patients will end up with life-long complications related to these procedures."

Phalloplasty is a complex surgery that involves constructing or reconstructing a penis using other skin parts, according to John Hopkins Medicine, while in vaginoplasties, "tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva."

"Phalloplasties carry uncertain long-term health risks; these may include fistulas, chronic infection, the need for a colostomy, atrophy, and complete loss of sensation, sexual or otherwise," Havrilla said.

Do No Harm is a nonprofit group of physicians and other medical professionals that gets its name from the Hippocratic oath: "First, do no harm." According to its website, Do No Harm is "fighting to curtail the unscientific and individually harmful practice of so-called 'gender affirming care'" for children.

“'Gender-affirming care' is based on the dangerous premise that any child who has distress that he or she thinks is related to their sex should automatically be treated with social transition to the sex of their choice followed by hormonal interventions and then possibly surgery to remove healthy body parts," it says. "Underlying mental health problems are usually not addressed."

According to Do No Harm's data, 2022 was the highest year for every state except for one when it came to the number of puberty or hormone blockers prescribed; the outlier was Alabama, which had 10 in both 2022 and 2023. 

When it came to the total number of transgender surgeries on minors, 21 out of 50 states had increases from 2022 to 2023.

Surgeries in California — which recorded the most gender reassignment procedures during the time period — dropped from 344 to 266 between 2022-23, while the number in Washington fell from 90 to 67 during the same time period. 

Nationwide, 42 states had higher puberty or hormone blocker prescriptions given to minors in 2023 than 2019, while 31 states had a higher number of surgeries in 2023 compared to 2019.

Do No Harm says its data was obtained through a variety of sources including “claims clearinghouses, data aggregators, payors, health systems, CMS, and multiple open data sources. The final product includes data from commercial insurance, Medicaid, Medicare, and VA claims.” Do No Harm says it was conservative when counting the number of procedures on children; if there was any doubt whether a procedure involved sex reassignment on a minor, it was excluded.

Of those procedures involving a minor, almost 40% were performed in just four states — California, New York, Washington, and Ohio. California had the highest number of total procedures at 2,083.

California was not among the top 10 states for procedures per capita, however. While Ohio ranked fourth in total procedures (1,020), it also ranked seventh in procedures per capita, at one per 11,568 residents. California’s per capita was one procedure per 18,981 residents, which was less than New Hampshire’s one per 10,678 residents.

Washington ranked third for both total procedures performed (1,082) and the number of procedures per capita, at one procedure per 7,121 residents.

The state with the highest gender reassignment procedure rate per capita was Oregon, which had 899 procedures but with a population of 4.2 million constituted one procedure per 4,713 residents. Hawaii, with a population of 1.46 million and 15 procedures, had the lowest rate at one procedure per 291,054 residents.

Though it ranked eighth for the number of total procedures (718), Massachusetts medical centers billed the third most for gender reassignment procedures on minors at $10 million. That's compared to $7 million in total charges in Washington, which had 364 more procedures. New York billed $19 million, while California medical providers billed the most at $29 million.

Although states such as Montana and Alabama enacted bans on those procedures in 2022, and Arkansas in 2021, Do No Harm’s data shows that all three states continued to have medical providers billing for these procedures into 2023.

Ohio now has a ban on gender reassignment surgery and hormone blockers. That law passed in January, beyond the scope of Do No Harm’s data timeframe. The law was upheld by a judge in August. Before the law went into effect, hospitals in Ohio treated 1,004 minors, including 224 surgeries.

Do No Harm also published a new database listing the hospitals where these procedures were conducted the most. According to Do No Harm's database, called "Does my hospital transition kids?", the hospitals where the most sex reassignment procedures and surgeries on children were conducted were at the Children's Hospital of Philadelphia, Connecticut Children's Medical Center, Children's Minnesota, Seattle Children's, and Children's Hospital Los Angeles.

The database, which is searchable by state, lists 225 hospitals where such procedures have occurred.

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States are banning gender-affirming care for minors. What does that mean for patients and providers?

More than 20 u.s. states have banned or severely limited treatment to align a young person’s body with their gender identity. that leaves some doctors caught between breaking the law and providing what they say can be lifesaving medical care..

States Restricting Gender-Affirming Care

Sue Ogrocki | AP

Trans-rights activists protest outside the House chamber at the Oklahoma state Capitol on Feb. 6, 2023, in Oklahoma City.

A large majority of transgender adults in the United States – 78% – say living with a gender different from the one assigned to them at birth has made them more satisfied with their lives, according to a survey from The Washington Post and KFF .

Among respondents, more than three-quarters had changed their type of clothing, hairstyle or grooming habits to align with their preferred gender, while 31% had used hormone treatments and 16% had undergone gender-affirming surgery or a related surgical treatment to alter their appearance.

But such options are becoming available on a more limited basis, as politicians in multiple states have attempted to restrict trans Americans’ ability to seek gender-affirming medical treatments.

What Is Gender-Affirming Care? 

The Department of Health and Human Services defines it as a “supportive” form of health care consisting of “an array of services that may include medical, surgical, mental health, and non-medical services for transgender and nonbinary people.” Treatment is tied to gender dysphoria, the medical term for distress experienced by “people whose gender at birth is contrary to the one they identify,” according to the American Psychiatric Association. Human Rights Campaign, an LGBTQ+ advocacy group, also writes that the American Medical Association, the American Academy of Pediatrics and the American Psychological Association recognize “that it is medically necessary to support people in affirming their gender identity.”

Conservatives often oppose the concept of gender-affirming care – which may or may not include surgery or other interventions – for various reasons, including religious beliefs and concerns about child abuse. “You don’t disfigure 10-, 12-, 13-year-old kids based on gender dysphoria,” Florida Gov. Ron DeSantis, a Republican, said at an August 2022 news conference.

Some have expressed concern about a lack of data on the possible long-term consequences of gender-affirming medical treatment for minors. A 2022 Reuters investigation , for example, found “no large-scale studies have tracked people who received gender-related medical care as children to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning.” Others, according to the article, have raised alarms about children who are not appropriately evaluated before receiving gender-affirming medical care. Guidelines from the World Professional Association for Transgender Health say evidence of regret about transitioning is scant, but patients should be told about the possibility during psychological counseling, according to The Associated Press .

These States Have Banned Gender-Affirming Care for Minors

Mississippi

New Hampshire

North Carolina

North Dakota

South Carolina

South Dakota

West Virginia

Below are the states that have moved to restrict some form of gender-affirming care for minors in 2023 and so far in 2024, based largely on legislation tracking from the Equality Federation, an advocacy accelerator that works with a network of state-based LGBTQ+ organizations.

Some states, such as Arizona and Alabama , passed bans prior to 2023 and are not included on the list.

Dozens of bills have been considered by lawmakers in other states, according to the federation. And officials elsewhere, including in Florida and Missouri, have bypassed state legislatures altogether.

Signed into law by new Republican Gov. Sarah Huckabee Sanders in March 2023, Arkansas’ law made health care providers liable for civil action for up to 15 years after a minor turns 18 if they performed a gender transition procedure on that minor – essentially making it easier to file malpractice lawsuits in these situations. On that note, experts say the law acts as a de facto ban on gender-affirming care for children because it makes it nearly impossible for providers to get malpractice insurance, according to the AP . In 2021, state lawmakers passed the nation’s first ban on gender-affirming care for minors. The move was temporarily blocked shortly after, but on June 20, 2023, a federal judge issued a permanent injunction against it, ruling the ban unconstitutional. It marked the first time such a state ban was overturned, but the more recent law signed by Sanders was still set to go into effect.

The state health department’s Board of Medicine announced a new rule in March of 2023 prohibiting several types of treatment and procedures – such as sex reassignment surgeries and puberty blockers – for treating gender dysphoria in minors. Then, in May of that year, DeSantis signed into law a similar gender-affirming care ban from the state Legislature . In June 2024, a federal judge ruled that key measures of the law were unconstitutional , including its restrictions on gender transition care for minors and provisions related to adults, such as a requirement to meet in person with a doctor prior to beginning treatment. But a federal appeals court in August blocked the lower court’s order and paved the way for Florida to enforce the ban amid the appeal process.

Senate Bill 140 was signed into law by Georgia Republican Gov. Brian Kemp in late March. The legislation , pushed forward by the Republican majority in the state’s General Assembly, prohibits “certain surgical procedures for the treatment of gender dysphoria in minors from being performed in hospitals and other licensed healthcare facilities.” There are exceptions, including treatments that are deemed “medically necessary” and situations covering continued treatment for minors undergoing “irreversible hormone replacement therapies” prior to July 1, 2023. A federal judge on Sept. 5, 2023, allowed Georgia to resume enforcing the portion of the law banning doctors from starting hormone therapy for transgender minors, weeks after blocking it with a preliminary injunction. The prohibition on surgical procedures was not covered by the legal challenges.

The state’s GOP Gov. Brad Little approved a bill that criminalizes providing gender-affirming care for youth. Signed on April 4, 2023, and set to go into effect in January 2024, the law was intended to make it a felony to provide hormones, puberty blockers or other gender-affirming medical care to minors. But in December 2023, a federal judge issued a temporary injunction blocking the law’s enforcement. Then the Supreme Court in April 2024 ruled that the state could enforce the ban against everyone except the plaintiffs who challenged it. Even before that ruling, Little in March 2024 signed a new law that will prevent transgender people in Idaho from using publicly funded programs to help cover the cost of gender-affirming care. The ban included in the legislation, which went into effect on July 1, 2024, extends to state employees on work health insurance and adults using Medicaid.

Republican Gov. Eric Holcomb signed into law on April 5, 2023, a bill banning all gender-affirming care for minors, after previously saying there was “some vagueness to it,” according to the AP. The governor said in a statement that “permanent gender-changing surgeries with lifelong impacts and medically prescribed preparation for such a transition should occur as an adult, not as a minor.” The parts of the law banning puberty blockers and hormone treatments for minors were blocked by a federal judge on June 16, 2023, following a request for a preliminary injunction by the American Civil Liberties Union of Indiana. But a federal appeals court ruling on Feb. 27, 2024, allowed those restrictions to go into effect.

Iowa’s ban , signed into law on March 22, 2023, prohibits health care professionals from “knowingly” performing certain medical practices on minors if they are “for the purpose of attempting to alter the appearance of, or affirm the minor’s perception of, the minor's gender or sex, if that appearance or perception is inconsistent with the minor's sex.” Practices covered by the law include hormone therapies and surgical procedures. As with other states’ laws, there are some exceptions, including a “medically verifiable disorder of sex development.”

The state on March 29, 2023, joined others in banning gender-affirming medical care for minors when the Republican-led Kentucky General Assembly voted to override Democratic Gov. Andy Beshear’s veto, becoming the first state led by a Democrat to approve such a ban in 2023. The law notes that any health provider who violates the prohibition can have their license or certificate revoked. A federal judge that June temporarily blocked the portion of the law that would have banned transgender youth from accessing puberty blockers and hormone therapy, but that same judge lifted the injunction on July 14 – allowing the restrictions to go into effect. A federal appeals court panel later that month allowed the state to continue enforcing the law – and so did another in September.

With a successful override attempt of former Democratic Gov. John Bel Edwards’ veto by the state’s Republican supermajority legislature, Louisiana approved a ban on gender-affirming care for minors on July 18, 2023. The law , which went into effect on Jan. 1, 2024, covers procedures such as hormone therapies, puberty blockers and gender-reassignment surgeries. The ban’s ultimate approval came after a Republican lawmaker cast a tie-breaking vote to kill the legislation in May. But it was eventually resurrected and passed before Edwards’ veto. New Gov. Jeff Landry, a Republican, has supported the ban, saying in a May 2023 social media post , “Pediatric sex changes should have no place in our society.”

Mississippi’s law – among the first to be enacted in 2023 – bans any person from knowingly providing or engaging in conduct that aids and abets the performance of gender transition procedures on a minor in the state. The ban also prohibits the use of public funds or tax deductions for such procedures. Republican Gov. Tate Reeves said when he signed the bill into law that “radical activists” are telling children they are “just a surgery away from happiness,” according to the AP .

GOP Gov. Mike Parson on June 7, 2023, signed a bill that will restrict gender-affirming health care for minors and some adults in Missouri starting in late August of that year. The law prevents the state’s Medicaid division from covering such treatment for people of any age, and prohibits providers from prescribing puberty-blockers or cross-sex hormones to minors until Aug. 28, 2027, unless they were being treated prior to the bill’s effective date. Missouri initially banned gender-affirming care in April 2023 through an emergency regulation from state Attorney General Andrew Bailey that limited treatments for both minors and adults, the latter of which was believed to be a first in the country . But Bailey terminated the rule – which had already been on pause due to a lawsuit – on May 16, citing the state legislature’s imminent ban. A circuit judge on Aug. 25, 2023, allowed the law to take effect.

Signed into law on April 28, 2023 , by Republican Gov. Greg Gianforte, Montana’s ban on gender-affirming care for minors covers both surgical procedures and medications such as puberty blockers and testosterone. As with other state laws, the prohibition has exceptions including for someone “diagnosed with a disorder of sexual development.” Any physician who performs a banned procedure can be also sued in the 25 years following it if the after-effects result in any injury, “including physical, psychological, emotional or physiological harms.” Democratic state Rep. Zooey Zephyr, a transgender woman, was exiled from the Montana House floor after she said her fellow Republican lawmakers would have “blood on their hands” if they passed the bill. The law was set to take effect on Oct. 1, 2023, but a state judge issued a preliminary injunction on Sept. 27 that blocked its enforcement, according to the AP. More than a year later, the state Supreme Court ruled in December 2024 that the law would remain temporarily blocked, sending the case back to a lower court for trial.

Republican Gov. Jim Pillen signed into law on May 22, 2023, a bill that limits gender-affirming medical care for minors, which covers people under the age of 19 in Nebraska. The law , which also bans abortions at 12 weeks of pregnancy, includes a ban on surgical procedures and limitations on “prescribed drugs related to gender alteration.” The regulations for hormone therapies – recommended by the state’s chief medical officer, a political appointee – were later approved by Pillen on March 12, 2024, and include a seven-day waiting period to start puberty-blocking medications or hormone treatments and a requirement for transgender patients under 19 to meet several therapy benchmarks. The gender-affirming care portion of the new law went into effect on Oct. 1, 2023. The law was challenged by a lawsuit but eventually upheld by the Nebraska Supreme Court , which ruled that it does not violate a state requirement that bills adhere to a single subject.

The Courage to Be Seen: Trans Women in South Florida

Republican Gov. Chris Sununu on July 20, 2024, signed into law a bill that prohibits physicians from performing gender-affirming surgeries on transgender minors. The ban, which takes effect on Jan. 1, 2025, includes an exception for “genital surgeries on minors with disorders of sex development.” The governor said in a statement that the bill had “earned bipartisan support.”

The state’s Republican-dominated legislature on Aug. 16, 2023, voted to successfully override a veto from Democratic Gov. Roy Cooper and approve a ban on gender-affirming care for minors in North Carolina. The bill’s language covers both transition surgeries and puberty-blocking drugs or cross-sex hormones. The law went into effect immediately, but as with other state bans that have been approved, there are some exceptions to the prohibition.

Republican Gov. Doug Burgum on April 19, 2023, signed into law a bill passed with a veto-proof majority that criminalizes providing gender-affirming medical care to minors. The law , which went into effect immediately as an “emergency measure,” makes performing sex reassignment surgery on a minor a felony, and makes providing gender-affirming medication such as puberty blockers to minors a misdemeanor. Burgum recommended in a statement that “thoughtful debate around these complex medical policies should demonstrate compassion and understanding for all North Dakota youth and their families,” according to the AP.

Republican Gov. Mike DeWine on Jan. 5, 2024, signed an executive order that prohibits young Ohioans from getting gender-affirming surgeries done before they turn 18. The order, which took effect immediately, came just a week after DeWine vetoed a bill from the state Legislature that would have instituted a broader restriction on gender-affirming care for minors, including hormone therapies. But on Jan. 24, the state Senate successfully voted to override the governor’s veto, meaning the more wide-reaching ban – which also prohibits transgender girls and women from girls’ and women’s sports teams at both the K-12 and collegiate level – was expected to take effect in 90 days. The law was blocked with a temporary restraining order on April 16, but a county judge ruled on Aug. 6 that it could go into effect.

GOP Gov. Kevin Stitt on May 1, 2023, signed into law a ban on gender-affirming care for minors in Oklahoma, saying he was “thrilled” to do so and “protect our kids.” The bill allows for any physician who knowingly provides gender transition procedures to be charged with a felony, but the prosecution must occur before the minor patient turns 45. The law went into effect immediately, but on May 18 the state agreed to not enforce it while opponents sought a temporary court order blocking it. A federal judge in October later declined to stop the law from taking effect.

GOP Gov. Henry McMaster announced May 21, 2024, he had signed legislation that bars health care providers from performing gender-transition surgeries on people under 18 years old. Health professionals also cannot provide puberty blockers or hormone treatments to those under 18. The law, which took effect immediately, additionally requires a school principal, vice principal or counselor at a public school to notify a child's parent in writing if the child asks to be addressed using a pronoun that does not match their sex at birth. The AP reports the legislation was amended to allow mental health counselors to discuss banned treatments and where they are legal, and notes that doctors can prescribe puberty blockers for some conditions as young as age 4.

Signed into law on Feb. 13, 2023, House Bill 1080 prohibits South Dakotan health care professionals from administering various types of gender-affirming procedures on minors. If a provider violates the law, the legislation requires a professional or occupational licensing board to revoke any license or certificate held by the provider. GOP Gov. Kristi Noem strongly supported the bill before signing it, according to the AP .

Tennessee’s legislation , which was signed by Gov. Bill Lee in March 2023, bans health care providers from performing or offering to perform a medical procedure on a minor if its purpose is to enable that minor “to identify with, or live as, a purported identity inconsistent with the immutable characteristics of the reproductive system that define the minor as male or female.” It also prohibits such procedures if the purpose is to treat “purported discomfort or distress from a discordance between the minor's sex and asserted identity.” There are exceptions, and the law establishes penalties for providers who violate it. Just days before its July 1, 2023, effective date, a federal judge temporarily blocked the law’s ban on transgender youth from accessing puberty blockers and hormone therapy. An appeals court later ruled in September that Tennessee could continue to enforce its ban while legal challenges played out. And in June 2024, the Supreme Court agreed to hear the state’s case during its next term, which would allow the high court’s justices to weigh in more directly on the issue of gender-affirming care access for minors. Arguments took place Dec. 4, with comments from justices indicating that the court is likely to uphold Tennessee’s law. A decision is expected by June 2025.

GOP Gov. Greg Abbott on June 2, 2023, signed a bill banning gender-affirming care for minors in Texas. The law contains exceptions similar to other states’ efforts at restricting transition care. The Texas Supreme Court on Aug. 31, 2023, allowed the law to go into effect on Sept. 1, overruling a state district judge who had issued a temporary injunction against the ban a week prior. The state’s high court in June 2024 upheld the law again . The measure’s passage was not Texas’ first attempt at limiting gender-affirming care: Abbott in 2022 ordered the investigation of families who were receiving such care, though his efforts have been blocked in court. On Oct. 17, 2024, Texas Attorney General Ken Paxton announced the state was suing a Dallas doctor , alleging she provided gender-affirming care to more than 20 youths in violation of the state’s law. The action marked one of the first times a state has sought to enforce such a gender care-related ban, according to the AP.

Republican Gov. Spencer Cox signed into law on Jan. 28, 2023, the first gender-affirming care ban of that year. The Utah legislature’s Senate Bill 16 restricts health providers from performing “sex characteristic surgical procedures on a minor for the purpose of effectuating a sex change” or hormonal transgender treatment on minors who weren’t diagnosed with gender dysphoria before July 1, 2023. Cox said his approval of the law was an effort at least in part to pause “these permanent and life-altering treatments for new patients until more and better research can help determine the long-term consequences,” the AP reported .

A law signed by GOP Gov. Jim Justice on March 29, 2023, prohibits minors from being prescribed hormone therapy and puberty blockers, or from receiving gender-affirming surgery. The law , which took effect in January 2024, contains an exception geared toward youth for whom “treatment with pubertal modulating and hormonal therapy is medically necessary to treat the minor’s psychiatric symptoms and limit self-harm, or the possibility of self-harm.” In these cases, the minor must receive consent from their parents or guardians along with two medical providers.

Republican Gov. Mark Gordon on March 22, 2024, signed into law a measure that prohibits gender-affirming medical care for transgender minors. The ban , which went into effect on July 1, covers treatment such as surgeries and puberty-blockers. While he did sign the bill, Gordon added that the legislation means the government is “straying into the personal affairs of families,” according to the AP.

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Tags: Arkansas , Florida , Georgia , Iowa , Mississippi , South Dakota , Tennessee , Utah , transgender people

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