Brief

Prohibiting Gender-Affirming Medical Care for Youth

March 2022

As of March 2022, 15 states have restricted access to gender-affirming care or are currently considering laws that would do so. The bills carry severe penalties for health care providers, and sometimes families, who provide or seek out gender-affirming care for minors. This study estimates the number of transgender youth at risk of losing access to gender-affirming care under these bills.

Highlights
Six states also include penalties for parents who facilitate minors’ access to gender-affirming medical care.
About half the bills would bar insurance providers from offering coverage for gender-affirming care.
A bill in Missouri would attempt classify gender-affirming care as child abuse similar to the order recently issued in Texas.
Data Points
58,200
transgender youth at risk of losing access to care because of state bans and policies
Brief

Due to government efforts over the past two years, more than 58,000 transgender youth and young adults across 15 states are in jeopardy of losing access to gender-affirming care. In total, more than a third1 of the 150,000 transgender youth ages 13-17 in the U.S. live in the 15 states that have restricted access to gender-affirming care or are currently considering laws that would do so. More than 4,000 young adults ages 18 to 20 would also be at risk of losing access to gender-affirming care under the three proposed bills that would apply to young people over the age of 18.

In 2021, the Arkansas legislature enacted a ban on gender-affirming care for minors,2 aiming to restrict access to treatment for nearly 1,500 transgender youth in the state.

In February 2022, the governor of Texas issued an order restricting access to gender-affirming medical care for transgender youth—including the use of hormones to delay puberty and to promote physical development that is consistent with a child’s gender identity. The order classifies the provision of gender-affirming care as “child abuse” and directs the state’s Department of Family and Protective Services to investigate any reported instances of health care providers or parents who provide or seek out gender-affirming care for children.3 The order impacts as many as 13,800 transgender youth in the state. Both the Arkansas law and Texas order are currently being challenged in court.4

As of March 2022, 13 other states are considering bills that would deny gender-affirming medical care to transgender youth.5 Access to gender-affirming care is in jeopardy for an additional estimated 42,950 transgender youth across these 13 states. State-specific estimates of the numbers of at-risk youth are provided in the table below.

The bills carry severe penalties for health care providers, and sometimes families, who provide or seek out gender-affirming care for minors. In each of these states, the bills would either criminalize health care providers who provide gender-affirming care to minors or subject them to discipline from state licensing boards.6 Bills in 10 states would also allow individuals to file civil suits for damages against medical providers who violate these laws.7 Bills in six states provide penalties for parents who facilitate minors’ access to gender-affirming medical care.8

About half of these bills would further limit access to gender-affirming care for transgender youth by barring certain insurance providers from offering coverage for gender-affirming care, by placing restrictions on the use of state funds or state facilities to provide this care, or by excluding gender-affirming care as a tax-deductible health care expense. Bills in seven states would prohibit certain health insurance plans from offering coverage for gender-affirming care.9 In eight states, bills would prohibit the use of state funds for gender-affirming care or more broadly prohibit distribution of state funds to any organization or individual that provides gender-affirming care to minors, seemingly regardless of what the funding is used for.10 In five states, bills would prohibit gender-affirming care by or in government-owned or operated facilities, and by individual providers employed by government entities.11 In four states, bills would exclude gender-affirming care as a tax-deductible health care expense.12

Finally, a bill proposed in Missouri would attempt to limit access to gender-affirming care by classifying it as child abuse similar to the order recently issued in Texas.13

Gender-affirming care, including the use of hormones to delay puberty and to promote the development of secondary sex characteristics that are consistent with a child’s gender identity, is recommended for transgender youth by the American Academy of Pediatricians and the Endocrine Society and is viewed by the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Psychiatric Association (APA) as evidence-based patient care.14  Moreover, the American Medical Association supports insurance coverage for gender-affirming care for transgender people.15

Research shows that gender-affirming care improves mental health and overall well-being for transgender people,16 including youth. A 2020 study published in Pediatrics found that access to pubertal suppression treatment was associated with lower odds of lifetime suicidal ideation among transgender adults.17 Similarly, research conducted by the Williams Institute concluded that risk of past-year suicide attempts was lower among transgender people who wanted and received gender-affirming medical care.18 More generally, research indicates that efforts to support transgender youth in living according to their internal sense of gender is associated with better mental health and feelings of safety at school, while efforts to change the gender identity of transgender people (i.e., conversion therapy) are associated with suicidality.19

a Children under the age of 13 would be impacted by the proposed bills but are not counted here due to the lack of reliable estimates of the number of transgender children of this age. b North Carolina and Oklahoma’s bills apply to people under the age of 21. c Alabama’s bill applies to people under the age of 19.

Prohibiting Gender-Affirming Medical Care for Youth

There are an estimated 53,800 transgender youth ages 13-17 who live in the 15 states that are currently considering or have enacted bans on access to gender-affirming medical care. There are an estimated 4,400 transgender young adults ages 18-20 who live in the three states that have proposed or enacted bans on access to gender-affirming medical care for people of those ages.

To Create the Arkansas Save Adolescents from Experimentation (SAFE) Act, H.B. 1570, 93rd General Assemb., 2021 Reg. Sess. (Ark. 2021), codified at Ark. Code §§ 20-9-1501 to -1504 (2021).

Letter from Greg Abbott, Governor, State of Tex., to Jaime Masters, Comm’r, Tex. Dep’t of Family & Protective Servs. (Feb. 22, 2022), https://gov.texas.gov/uploads/files/press/O-MastersJaime202202221358.pdf.

Enforcement of Arkansas’s ban was blocked by a district court in July 2021. The case is now on appeal to the Eighth Circuit. Brandt v. Rutledge, 4:21-cv-00450-JM, 2021 U.S. Dist. LEXIS 135534 (E.D. Ark. July 21, 2021). A Texas court also blocked enforcement of the governor’s order. Order Granting Plaintiffs’ Application for Temporary Injunction, Doe v. Abbott, No. D-1-GN-22-000977 (Tex. Dist. Mar. 11, 2022).

These states are Alabama (S.B. 5/H.B. 150, and S.B. 184/H.B. 266), Arizona (S.B. 1138, S.B. 1045, S.B. 1130, and H.B. 2608), Georgia (H.B. 401), Iowa (H.F. 193), Kansas (H.B. 2210), Kentucky (H.B. 253/S.B. 84), Louisiana (H.B. 570), Missouri (H.B. 2649 and S.B. 843), North Carolina (S.B. 514), Ohio (H.B. 454), Oklahoma (S.B. 583, S.B. 676, and H.B. 3240), South Carolina (H.B. 4047), and Tennessee (S.B. 657/H.B. 578 and H.B. 2835/S.B. 2696). See Legislative Tracker, Freedom for All Am., https://freedomforallamericans.org/legislative-tracker (last visited Mar. 15, 2022); Legislation Affecting LGBT Rights Across the Country, ACLU (Mar. 14, 2021), https://www.aclu.org/ legislation-affecting-lgbtq-rights-across-country. Per publicly available materials, such bills introduced in Florida, Indiana, Mississippi, New Hampshire, and Utah no longer appear under consideration for this legislative session. Id.

More specifically, seven states would make it a felony for health care professionals to provide gender-affirming care (Alabama, Arizona (all except S.B. 1138), Georgia, Idaho, Kansas, Oklahoma (S.B. 676 only), and South Carolina) and one state would make provision of care a misdemeanor (Tennessee, S.B. 657 and H.B. 578 only). Eleven states would allow or require state licensing boards to discipline health care professionals who provide gender-affirming care, including by revoking or suspending state licenses required to practice (Arizona (H.B. 2608 only), Georgia, Iowa, Kansas, Kentucky, Louisiana, Missouri, North Carolina, Ohio, Oklahoma (H.B. 3240 and S.B. 583 only), and Tennessee).

These states are Arizona (H.B. 2608 only), Georgia, Iowa, Kentucky, Louisiana, Missouri (H.B. 2649 only), North Carolina, Ohio, Oklahoma (H.B. 3240 only), and Tennessee.

These states are Alabama, Idaho, Kansas, North Carolina, Oklahoma (S.B. 676 only), South Carolina, and Tennessee.

These states are Arizona (H.B. 2608 only), Kentucky, Louisiana, Missouri (H.B. 2649 only), Ohio, Oklahoma (H.B. 3240 only), and Tennessee. States cannot enact laws that regulate self-funded insurance plans (such as employer-sponsored health plans offered by private sector employers) due to the Employee Retirement and Income Security Act (ERISA). As a result, these bills would not affect coverage for gender-affirming care offered through these plans. See ERISA Plans, KFF.org https://www.kff.org/wp-content/uploads/ sites/3/2015/06/c11.pdf (last visited Mar. 10, 2022).

These states are Arizona (H.B. 2608 only), Kentucky, Louisiana, Missouri (H.B. 2649 only), North Carolina, Ohio, Oklahoma (H.B. 3240 only), and Tennessee (H.B. 2835/S.B. 2696 only).

These states are Arizona (H.B. 2608 only), Kentucky, Louisiana, Missouri (H.B. 2649 only), and Ohio.

These states are Arizona (H.B. 2608 only), Kentucky, Missouri (H.B. 2649 only), and Ohio.

S.B. 843.

American Academy of Child & Adolescent Psychiatry (AACAP). (2019, November 8). AACAP Statement Responding to Efforts to Ban Evidence-Based Care for Transgender and Gender Diverse Youth. Retrieved from https://www.aacap.org/AACAP/Latest_News/AACAP_ Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx; American Psychiatric Association (APA). (2021, April 2). Frontline Physicians Oppose Legislation That Interferes in or Criminalizes Patient Care. Retrieved from https://www.psychiatry.org/newsroom/news-releases/frontline-physicians-oppose-legislation-that-interferes-in-or-criminalizes-patient-care.; Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J.D., Tangpricha, V., & T’Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869-3903.; Rafferty J, American Academy of Pediatrics [AAP] Committee on Psychosocial Aspects of Child And Family Health, AAP Committee On Adolescence, AAP Section On Lesbian, Gay, Bisexual, And Transgender Health And Wellness. (2018). Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics; 142(4), 1-14.

American Medical Association and GLMA (2019). Health insurance coverage for gender affirming care of transgender patients. Issue brief. Retrieved from https://www.ama-assn.org/system/files/2019-03/transgender-coverage-issue-brief.pdf

Cornell University Public Policy Research Portal. (2017). What does the scholarly research say about the effect of gender transition on transgender well-being? Retrieved from https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people

Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2), 68-76

Herman, J. L., Brown, T. N. T., & Haas, A. P. (2019). Suicide Thoughts and Attempts Among Transgender Adults Findings from the 2015 U.S. Transgender Survey. The Williams Institute, Los Angeles, CA. Retrieved from https://williamsinstitute.law.ucla.edu/research/suicide-transgender-adults

Clark, T. C., Lucassen, M. F., Bullen, P., Denny, S. J., Fleming, T. M., Robinson, E. M., & Rossen, F. V. (2014). The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth’12). Journal of Adolescent Health; 55, 93-9; McGuire, J. K., Anderson, C. R., Toomey, R. B. & Russell, S. T. (2010). School climate for transgender youth: a mixed method investigation of student experiences and school responses. Journal of Youth and Adolescence, 39, 1175-88; Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A.H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503-505; Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. Journal of Adolescent Health, 53, 791-3;Turban, J. L., King, D., Reisner, S. L., & Keuroghlian, A. S. (2019) Psychological attempts to change a person’s gender identity from transgender to cisgender: Estimated prevalence across US States, 2015. American Journal of Public Health, 109, 1452-1454; Wilson, E. C., Chen, Y.-H., Arayasirikul, S., Raymond, H. F., & McFarland, W. (2016). The impact of discrimination on the mental health of trans*female youth and the protective effect of parental support. AIDS and Behavior, 20(10), 2203–2211.