Brief

Prohibiting Gender-Affirming Medical Care for Youth

April 2021

During this legislative session, Arkansas passed a bill denying gender-affirming care for youth. Nine other states are still considering similar bills. Most of these bills would penalize medical providers for delivering gender-affirming care to minors. A few states would penalize parents who seek gender-affirming medical care for their children.

Highlights
Six states also include penalties for parents who encourage or facilitate minors’ access to gender-affirming medical care.
Three states would prohibit school employees from withholding information about a child being transgender from their parents.
Three states have included insurance-related provisions within their proposed bills.
Data Points
45,100
transgender youth at risk of losing access to care because of state bans
1,450
transgender youth live in Arkansas
Brief

 This legislative session, lawmakers in 21 states introduced bills to deny gender-affirming medical care to transgender youth.1 To date, one state, Arkansas,2 has passed legislation denying gender-affirming care for youth and nine other states are still considering these bills: Alabama,3 Florida,4 Louisiana,5 Missouri,6 Montana,7 North Carolina,8 South Carolina,9 Tennessee,10 and Texas.11 Access to gender-affirming care is in jeopardy for an estimated 45,100 transgender youth across these ten states. State-specific estimates of the numbers of at-risk youth are provided in the table below. 

Most of these bills propose to make it a crime or a cause for professional discipline for medical providers to deliver gender-affirming care to minors. Bills in Louisiana, Missouri, North Carolina, South Carolina, Tennessee, and Texas also include penalties for parents who encourage or facilitate minors’ access to gender-affirming medical care. In three other states—Alabama, Louisiana, and South Carolina—school employees would be prohibited from withholding information about a child being transgender from that child’s parents, while a similar requirement proposed in North Carolina would apply to all state employees. The bill passed in Arkansas, and bills under consideration in Louisiana, Montana, North Carolina, and Tennessee, would allow individuals to file civil suits for damages against medical providers who violate these laws. Bills in Arkansas and Montana provide mechanisms for the state Attorneys General to file suit against medical providers to enforce compliance. 

Finally, three states have included insurance-related provisions within their proposed bills. In Texas, one set of bills would prohibit professional liability policies for medical providers from providing coverage for damages related to providing gender-affirming medical care to a minor. Arkansas’s bill prohibits health plans from covering reimbursement for gender-affirming medical care provided to minors under the age of 18 and does not require insurance plans to provide coverage for gender-affirming medical care—regardless of the beneficiary’s age. North Carolina’s bill prohibits the use of state funds to provide gender-affirming care or support the administration of governmental health plans that provide coverage for such care.

Gender-affirming medical care is recommended for transgender youth by the American Academy of Pediatricians and the Endocrine Society12 and is viewed by the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Psychiatric Association (APA) as evidence-based patient care (AACAP, 2019; APA, 2021; Hembree et al., 2017; Rafferty, 2018). Gender-affirming medical care includes the use of hormones to delay puberty and to promote physical development that is consistent with a child’s gender identity (their internal sense of who they are). Research shows that gender-affirming care improves mental health and overall well-being for transgender people (Cornell, 2017), including youth. A recent study published in Pediatrics found that access to pubertal suppression treatment was associated with lower odds of lifetime suicidal ideation among transgender adults (Turban et al., 2020). Similarly, a study 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 (Herman, 2019). 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 (Clark et al., 2014; McGuire et al., 2010; Russell et al., 2018; Simons et al., 2013; Turban et al., 2019; Wilson et al., 2016). 

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’s bill applies 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

These states include Alabama (S.B. 10 and H.B. 1), Arizona (S.B. 1511), Arkansas (H.B. 1570 and S.B. 347), Florida (H.B. 935), Georgia (H.B. 401), Indiana (S.B. 224), Iowa (H.F. 193), Kansas (S.B. 214 and H.B. 2210), Kentucky (H.B. 477 and H.B. 336), Louisiana (S.B. 104 and H.B. 575), Mississippi (S.B. 2171), Missouri (H.B. 33 and S.B. 442), Montana (H.B. 427 and H.B. 113), New Hampshire (H.B. 68), North Carolina (S.B. 514), Oklahoma (S.B. 676 and S.B. 583), South Carolina (H.4047), Tennessee (H.B. 578, S.B. 657, S.B. 126, and H.B. 1027), Texas (S.B. 1311, H.B. 2693, S.B. 1646, H.B. 4014, H.B. 68, and H.B. 1399), Utah (H.B. 92), and West Virginia (H.B. 2171). See Legislative Tracker, Freedom for All Am., https://freedomforallamericans.org/legislative-tracker (last visited Apr. 8, 2021); Legislation Affecting LGBT Rights Across the Country, ACLU (Apr. 2, 2021), https://www.aclu.org/legislation-affecting-lgbt-rights-across-country. Per publicly available materials, Montana H.B. 113 and the bills in Arizona, Georgia, Indiana, Iowa, Kansas, Kentucky, Mississippi, New Hampshire, Oklahoma, Utah, and West Virginia no longer appear under consideration for this legislative session. Id. 

To Create the Arkansas Save Adolescents from Experimentation (SAFE) Act, H.B. 1570, 93rd General Assemb., 2021 Reg. Sess. (Ark. 2021), https://www.arkleg.state.ar.us/Bills/Detail?tbType=&id=hb1570&ddBienniumSession=2021%2F2021R. 

Vulnerable Child Compassion and Protection Act, S.B. 10, 2021 Reg. Sess. (Ala. 2021), http://alisondb.legislature.state.al.us/ALISON/ SearchableInstruments/2021RS/PrintFiles/SB10-int.pdf; Vulnerable Child Compassion and Protection Act, H.B. 1, 2021 Reg. Sess. (Ala. 2021), http://alisondb.legislature.state.al.us/ALISON/SearchableInstruments/2021RS/PrintFiles/HB1-int.pdf. 

Vulnerable Child Protection Act, H.B. 935, 2021 Reg. Sess. (Fla. 2021), https://www.flsenate.gov/Session/Bill/2021/935/BillText/Filed/ PDF. 

S.B. 104, 2021 Reg. Sess. (La. 2021), https://legis.la.gov/legis/ViewDocument.aspx?d=1208865; Vulnerable Child Protection Act, H.B. 575, 2021 Reg. Sess. (La. 2021), https://legis.la.gov/legis/ViewDocument.aspx?d=1212045. 

H.B. 33, 101st Reg. Assemb., 1st Reg. Sess. (Mo. 2021), https://www.house.mo.gov/billtracking/bills211/hlrbillspdf/0931H.01I.pdf; S.B. 442, 101st Reg. Assemb., 1st Reg. Sess. (Mo. 2021), https://www.senate.mo.gov/21info/pdf-bill/intro/SB442.pdf. 

Youth Health Protection Act, H.B. 427, 67th Leg. (Mont. 2021), https://leg.mt.gov/bills/2021/HB0499/HB0427_1.pdf. 

Youth Health Protection Act, S.B. 514, 2021–2022 Sess. (N.C. 2021), https://ncleg.gov/Sessions/2021/Bills/Senate/PDF/S514v0.pdf. 

South Carolina Minor Child Compassion and Protection Act, H.4047, 124th Sess. (S.C. 2021), https://www.scstatehouse.gov/ sess124_2021-2022/prever/4047_20210309.htm.

H.B. 578, 112th General Assembly (Tenn. 2021), https://www.capitol.tn.gov/Bills/112/Bill/HB0578.pdf; S.B. 657, 112th General Assembly (Tenn. 2021), https://www.capitol.tn.gov/Bills/112/Bill/SB0657.pdf; S.B. 126, 112th General Assembly (Tenn. 2021), https:// www.capitol.tn.gov/Bills/112/Fiscal/FM0664.pdf; H.B. 1027, 112th General Assembly (Tenn. 2021), https://www.capitol.tn.gov/ Bills/112/Fiscal/FM0664.pdf. 

S.B. 1311, 87th Leg., Reg. Sess. (Tex. 2021), https://capitol.texas.gov/tlodocs/87R/billtext/pdf/SB01311I.pdf; H.B. 2693, 87th Leg., Reg. Sess. (Tex. 2021), https://capitol.texas.gov/tlodocs/87R/billtext/pdf/HB02693I.pdf; S.B. 1646, 87th Leg., Reg. Sess. (Tex. 2021), https://capitol.texas.gov/tlodocs/87R/billtext/pdf/SB01646I.pdf; H.B. 4014, 87th Leg., Reg. Sess. (Tex. 2021), https://capitol.texas.gov/ tlodocs/87R/billtext/pdf/HB04014I.pdf; H.B. 68, 87th Leg., Reg. Sess. (Tex. 2021), https://capitol.texas.gov/tlodocs/87R/billtext/pdf/ HB00068I.pdf; H.B. 1399, 87th Leg., Reg. Sess. (Tex. 2021), https://capitol.texas.gov/tlodocs/87R/billtext/pdf/HB01399I.pdf.

More specifically, care is recommended for those with a diagnosis of gender dysphoria—defined by the American Psychiatric Association as “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration (Rafferty, 2018; Hembree et al., 2017; APA, 2013).”