State legislatures are off and running in 2023, and across dozens of states, a big issue for legislators is health care for transgender people, particularly the subset known as gender-affirming care.
In 2023 alone, legislators have introduced more than 100 bills across 31 states that would restrict gender-affirming care, according to civil rights advocates at the ACLU. The bills usually address health care for people under 18 years old.
It's part of a broader push to restrict aspects of transgender life, alongside recent laws governing the presence of trans people in everything from bathrooms to sports.
Transgender people say these laws are an attack on their human rights and access to basic health care.
"I could stand here and tell you about the times I attempted to end my life because I didn't have access to gender-affirming care, but I know, I know you don't care. I see you sneering at us," said Lindsey Spero, a transgender Florida resident.
"I take issue with describing some of the care, particularly surgery, as mutilation," said State Rep. Zooey Zephyr, (D) Montana. "As someone who has undergone gender-affirming surgery, I know the light it brought to my life."
Legislative sponsors of these bills tend to be Republican. They say providing this care is a threat to the well-being of children.
"As adults, we understand that a child's brain is not fully formed and cannot comprehend the ramifications of making irreversible medical decisions," said State Sen. Kathleen Kauth, (R) Nebraska.
"It's my hope and the hope of this bill that by the age of 18, they will not want to pursue further physical or chemical treatments or pursue those treatments," said State Sen. Julie Daniels, (R) Oklahoma.
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Some states are moving to ban gender-affirming care for minors. But lawmakers are pushing to improve protection for minors, parents and providers.
So, what exactly is gender-affirming care?
It's a set of guidelines for doctors that tell them to support and affirm a patient's gender identity when it doesn't match how they were assigned at birth. It includes everything from using proper pronouns with patients, to counseling and therapy, and medical options like puberty blockers, hormones and sometimes surgery.
Radiologist and breast imaging doctor Evelyn Carroll, a trans woman herself, says gender-affirming care by its nature has to be pretty broad.
"Gender affirmation is gonna look different for everyone," she said. "I like to say that if you know one transgender person, you know one transgender person. And for some people, that may include hormones and surgeries, but for others, often there is no medical component of their gender and their gender affirmation."
Doctors providing this care see it as a standard of care for a vulnerable group. Studies show this care can be life-saving, directly linking gender-affirming care to lower rates of depression and suicidality.
That really matters for the transgender community. A study published last year in the Journal of Interpersonal Violence found that 82% of transgender people surveyed reported suicidality, and 40% had attempted suicide.
While bills banning medical aspects of gender-affirming care say they aim to protect kids, leading medical associations say they have already built a framework to do just that. Plus, almost every relevant large medical association is on board with the basic concept of providing nonjudgmental care that affirms a patient's gender identity.
Scripps News reached out to the American Medical Association, American Psychological Association, American Academy of Pediatrics, Endocrine Society, World Professional Association for Transgender Health and the American Academy of Obstetricians and Gynecologists. All of them support gender-affirming care and have set up standards for how to provide that care responsibly. Though specific guidance around issues like age minimums for certain treatments can vary, they're on the same page about the broader framework.
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The temporarily blocked law prohibits doctors from providing gender-confirming hormone treatment, puberty blockers or surgery to anyone under 18.
While not everybody chooses to medically transition, most bills have sought to prevent people under 18 from accessing puberty blockers and hormone therapy, as well as surgeries.
American Academy of Pediatrics guidance asks doctors, parents and young patients to work together to figure out which treatments are right for them. Dr. Jason Rafferty led the development of their guidance, and he explained to Scripps News some of the most common medical treatments.
Firstly, there are puberty blockers. If a young person is considering a transition or just isn't sure of their gender identity, a doctor can prescribe these to give a child more time to figure things out. Best practices dictate that these aren't prescribed until a child is at puberty age.
"Puberty blockers can be very valuable at that stage because, especially for a young person who feels that their body is beginning to change, they don't have control," Rafferty said. "It's really distressing, you know, and it seems like for a young person, what I often hear from my patients is it feels like it happens fast, like things start moving and things start happening fast. And so the goal with puberty blockers is just to slow the process down."
Puberty resumes after a patient stops taking the blockers, and most of their effects are reversible. But the threat of long-term bone density loss has led some European institutions to pause their use. Rafferty says that specific issue can occur if blockers are used for too long or too late into puberty.
The American Academy of Pediatrics also notes more research is needed into potential risks to fertility.
Patients can also undergo hormone therapy, getting either testosterone or estrogen to align more closely with their gender. These treatments are meant for later into puberty and aren't considered under guidelines until age 14 at the earliest, with most providers waiting until a patient is at least 16. Hormones have less reversible effects on things like voice, hair follicles, breast size and, potentially, fertility.
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An executive order is discouraging "conversion therapy" — a discredited practice that aims to change a person's sexual orientation or gender identity.
"We want to make sure that young people can sort of reflect back and sort of be able to talk through why this is going to be beneficial for them," Rafferty said. "We want to make sure that young adults are really thinking through reversible, irreversible when it comes to sort of effects, side effects, things like that."
After months or years of blockers and hormone therapy, patients who want to go further can get top and/or bottom surgery. Surgeries generally aren't done before age 18 but can be performed for those slightly younger if doctors and the patient agree it's necessary.
"By and large, surgery is reserved for adult populations above the age of majority," Rafferty said. "There are some exceptions specifically for what is referred to as top surgery, which would be sort of, you know, manipulating the chest for a mature 16 or 17 year old on a case-by-case basis."
WPATH guidance does open the door for it to happen at age 15 but only in countries where 15 is the age of majority, meaning the age where a person is legally an adult. The age of majority in the U.S. is 18 years old.
Even then, Rafferty explained that any surgery for minors isn't something doctors take lightly.
"It is usually a fairly intensive process of multiple team members weighing in to make sure that this is a qualifying sort of case, that this would be a sort of exception," Rafferty said. "When we talk about bottom surgery, which would include any sort of sterilizing procedure or any sort of genital procedure, that is not something that any existing protocol today is really sort of endorsing under the age of majority."
Gender-affirming care is something adults seek out, too. Some doctors worry that the political push for more restrictions on this kind of care could end up impacting patients of all ages.
