NOTE: Most of this was written in 2023 or earlier and needs an overhaul as of 9/12/25
Gender Affirming Care (GAC) can be defined as medical care needed to bring a person’s body more into congruence with their gender identity. One might consider breast reduction surgery for a cisgender male or facial hair removal through medication, laser, or electrolysis of a cisgender woman with PCOS (polycystic ovarian syndrome) to be gender affirming care but the legislation discussed here either doesn’t address or makes specific exceptions for such care. GAC for trans people, aka medical transitioning, has been practiced in a formal way for over a century and there are aspects practiced before modern medicine stretching back over 2500 years. Different states have passed different restrictions and enshrined different rights to GAC with most of the restrictions placed on minors.
Many states have enacted laws with explicit civil or criminal liability for practitioners or gender affirming care. Even without such penalties being made explicit, practitioners in states with GAC restrictions are finding higher malpractice insurance rates which may be prohibitive.
In addition, as detailed in the section relating to religious and freedom of conscience exemptions, some laws allow health care providers to withhold care based on their personal moral code.
GAC Bans.
First, some historical context:
There was never really a time when GAC for trans people went from being banned to first being allowed. While similar surgeries were performed around the world on intersex people from the late 1800s forward, genital surgeries were first performed on trans people in Germany in the 1920s and early 1930s and began to be performed elsewhere through the 1940s and 1950s.
Hormone therapy for trans people was first documented in 1928, the same year as such therapy became available for cis people, though it became much more common for both in the late 1940s. Medical interventions for teenagers happened rarely in the late 1940s, occasionally through the 1950s, and more frequently in the 1960s, mostly for late teens, mostly hormone therapy only, occasionally breast reductions for trans boys in their late teens by the late 1960s. Up through the 1970s, the medical establishment saw transsexualism (in the language of the era) as a problem to be solved and only reluctantly grew to admit that there was no imposing a cisgender identity onto a trans person, even at very young prepubescent ages, and that affirming their gender identity led to their best outcomes.
Puberty blockers became available to treat cisgender children with precocious puberty around 1980 and were being tried in the late 1980s in Denmark as a way of treating transgender teens. Many trans teens had already been treated with standard hormone therapy from decades earlier. By the late 1990s blockers had made their way to the United States and are part of the treatment plan recommended by the Endocrine Society and WPATH. Still, very few trans youth actually have access to or take puberty blockers or hormone therapy and almost none undergo surgeries prior to age 18. Those surgeries are typically limited to breast reductions for trans boys ages 17 or 18. Puberty blockers are not useful to start once puberty has progressed beyond a certain point. For those trans folks might begin medical interventions directly with hormone therapy.
Before 2020, you didn’t see many GAC ban bills, and most of what there was were bills wanting to ban GAC for prisoners or to ban state Medicaid programs from paying for them. Model bills began to take shape in 2017, but bills to actually ban GAC for minors didn’t begin to appear until 2018, and didn’t pick up steam until the Vulnerable Child Protection (VCP) Act appeared across the country in 2020.
Many of these bans have common model bill origins and names including:
The Vulnerable Child Protection Act (VCPA) by a coalition of groups
The Help Not Harm Act (HNHA) (aka The Save Adolescents From Experimentation (SAFE) Act) by Family Policy Alliance / Family Research Council
The JUST Facts Act by Do No Harm
The VCP Act was a model bill assembled by groups coordinated by South Dakota Senator Deutsch. In the summer of 2017, he began coordinating with several anti-trans organizations to construct a gender affirming health care ban for minors which eventually became the VCP Act. It failed on first introduction in 2020, but served as a template for future efforts and the megagroup continued to co-ordinate its legislative efforts. South Dakota did pass such a ban in February 2023. This group included Alliance Defending Freedom (ADF), the American College of Pediatricians (ACPeds), the Eagle Forum, Christian Medical & Dental Associations, The Heritage Foundation, The Family Policy Alliance, and the American Principles Project.
The SAFE Act, is a boilerplate, model bill put forward by the Family Research Council, which is branded as a hate group by the Southern Poverty Law Center, is an American evangelical activist and think tank group which lobbies against stem cell research, abortion rights, homosexuality (including advocating for Uganda's anti gay laws), divorce, and pornography, and is a subdivision of Focus on the Family. Focus on the Family itself has been pushing against trans rights since at least 2008.
The Arkansas version of the SAFE Act is under injunction by the U.S. 8th Circuit Court of Appeals, while similar bans in Tennessee and Kentucky have been lifted by the 6th Circuit Court of Appeals, so that these cases will be heading for SCOTUS (meanwhile in the past three years, 26 such bans have gone into effect, mostly during 2023).
The JUST Facts Act is another model bill behind much of the anti GAC legislation, assembled by a group calling itself Do No Harm.
Some states have proposed GAC bans regardless of age. A few have proposed bans for those below age 26 or below age 21. Others have passed restrictions which make GAC technically legal for those above the age of majority, but put in place enough logistical impediments to make it practically impossible for most.
Following the pattern of prohibitions and restrictions on abortion, newer laws and bills have sought to restrict the use of public funds or facilities from being used to provide gender affirming medical care.
The following states have restrictions on GAC beyond the age of majority.
Florida 2022 S 254 among other things, this requires adults sign factually inaccurate consent forms with a physician present in person in order to have prescriptions for hormone therapy renewed. Most prescribing health care providers who operate in person are not physicians but are nurse practitioners and the like.
Idaho 2024 H 668 forbids the spending of public money, the use of state, county, or local government owned buildings or property, or the services of state, county, or local government employed physicians or other health professionals to provide gender affirming medical or surgical care. This also has the effect of blocking GAC for those in prisons, but an injuction in the Federal District Court for Idaho on 8/4/2024 requires prisoners continue to receive GAC.
Ohio, through a January 2024 executive order, requires an endocrinologist and psychiatrist to develop a treatment plan for trans people of all ages, which must then be approved by a medical ethicist - a position which is in prohibitively short supply.
South Carolina 2024 H 4624 blocks GAC for minors, blocks Medicaid spending for all under the age of 26, and blocks the use of public funds or facilities for providing or aiding the provision of GAC to people of all ages.
The following states have restrictions on GAC (puberty blockers, hormone therapy, and surgeries unless otherwise noted) for people up through and including age 18:
Alabama 2022 SB 184 Class C Felony crime V-CAP
Nebraska 2023 LB 574 Let Them Grow Act (V-CAP language)
The following states have restrictions on GAC (puberty blockers, hormone therapy, and surgeries unless otherwise noted) for people up through and including age 17:
Arizona 2022 SB 1138 Surgery ban only (Help Not Harm language)
Arkansas 2021 HB 1570 SAFE Act (makes all GAC for minors illegal); 2023 SB 199 A “JUST FACTs Act” (makes GAC for minors arduous to obtain and blocks those who have a variety of conditions like autism, ADHD, depression, etc. from having GAC as minors).
Florida 2023 S 254 Felony crime
Georgia 2023 SB 140: bans surgery and hormone therapy but not puberty blockers. Blocked by district court 8/23
Idaho 2023 H 71: Felony crime, Vulnerable Child Protection Act
Indiana 2023 SB 480
Iowa 2023 SF 538
Kentucky 2023 SB 150
Louisiana 2023 HB 648 Stop Harming Our Kids Act
Mississippi 2023 HB 1125 Regulate Experimental Adolescent Procedures (REAP) Act
Missouri 2023 SB 49 SAFE Act
Montana 2023 SB 99 Youth Health Protection Act (A JUST FACTs Act, Blocked in District Court)
New Hampshire 2024 HB 619 (Surgery only)
North Carolina 2023 H 808
North Dakota 2023 HB 1254 Felony crime
Ohio 2023 HB 68 SAFE Act
Oklahoma 2023 SB 613 Felony crime
South Carolina 2024 H 4624
South Dakota 2023 HB 1080
Tennessee 2023 SB 1 (Currently under challenge in United States v. Skrmetti set to be heard by SCOTUS in 24/25)
Texas 2023 SB 14
Utah 2023 SB 16
West Virginia 2023 HB 2007 but with parental consent and multiple physician documentation hormone therapy and puberty blockers may be permitted.
Wyoming 2024 SB 99 Chloe’s Law.
Medicaid Bans
Medicaid policy is set up on a state-by-state basis, and often the requirements a state sets for its Medicaid program are mirrored in private insurance policies available to that state, thus where Medicaid provides coverage of GAC, GAC is affordable, and where Medicaid is forbidden from providing coverage of GAC, GAC, if legal, is only available to the wealthy and upper middle class.
The following states and municipalities have GAC coverage requirements for Medicaid
Alaska
California
Colorado
Connecticut
Delaware
District of Columbia
Georgia
Iowa
Illinois
Maine
Maryland
Massachusetts
Michigan
Minnesota
Montana
Nevada
New Hampshire
New Jersey
New York
North Dakota
Oregon
Pennsylvania
Puerto Rico
Rhode Island
Wisconsin
Vermont
Virginia
Washington
Wisconsin
The following states have GAC coverage bans for Medicaid
Arizona
Arkansas (ban for minors only; blocked in court);
Florida (ban blocked in court)
Idaho 2024 H668
Kentucky
Mississippi (ban for minors only)
Missouri
Nebraska
North Carolina (ban for minors only)
Ohio (ban not enforced)
South Carolina 2024 H 4624 (directly for under age 26; indirectly through restrictions on public funds and facilities for all ages)
Tennessee
Texas
Insurance
Some states prohibit discrimination in insurance coverage based on sexual orientation and or gender identity. Some prohibit excluding coverage of transgender specific healthcare. A couple explicitly permit private insurers to refuse to provide gender affirming care. Some states’ employee health benefits explicitly include coverage of gender affirming care and some explicitly exclude it.
States with trans and other LGBTQ+ protective health insurance laws and GAC coverage for public employees
California
Colorado
Connecticut
Delaware
District of Columbia
Hawaii
Illinois
Maine
Maryland: requires GAC coverage for private insurance but does not have explicit anti-discrimination protections
Massachusetts
Michigan
Minnesota
Nevada
New Hampshire
New Jersey
New Mexico
New York
Oregon
Pennsylvania
Rhode Island
Vermont
Virgina
Washington
Wisconsin
States with trans and other LGBTQ+ discriminatory health insurance laws and/or forbid GAC coverage for public employees
Arkansas: allows private insurance GAC exclusions
Mississippi: allows private insurance GAC exclusions for minors
A number of states have laws which make the claim that people should be allowed to withhold services in one manner or another if to provide them would violate the First Amendment by violating their religious beliefs or their “Freedom of Conscience”. Some of these laws fall under the framework of state level Religious Freedom Restoration Acts. Others were modeled after a model bill called “Protecting Freedom of Conscience from Government Discrimination Act”. The 2014 SCOTUS decision Burwell v. Hobby Lobby Stores Inc. found that for-profit corporations could be considered persons under the RFRA allowing the company to not provide insurance for contraceptive services due to religious reasons. This prompted interested parties to explicitly write bills to allow religious exclusions to insurance and other health care provision requirements.
The following states have health care oriented “Freedom of Conscience” Acts allowing a medical provider, health care institution, or medical payer may refuse to participate in health care service on the basis of conscience. This can be particularly prohibitive in states where many hospitals are religiously affiliated and where the nearest non-affiliated hospitals are hundreds of miles away. Some of these are general. Many specifically mention abortion. Some mention transgender health care specifically. Some mention sterilization specifically, which is something that can result from some forms of transgender medical care, but does not result from puberty blockers.
Alabama 2017 HB 95 Health Care Rights of Conscience Act: abortion and sterilization specifically mentioned.
Arkansas 2021 SB 289 Act 462: Medical Ethics and Diversity Act;
Florida 2023 S 1580 Protections of Medical Conscience
Illinois (745 ILCS 70/) Health Care Right of Conscience Act. (1/1/2017 amendments)
Mississippi 2016 HB 1523 Protecting Freedom of Conscience from Government Discrimination Act: Blanket exemptions for discrimination protection on the basis of "biological sex" for various facilities, medical services, counseling, etc.
Montana 2023 HB 303- Medical Ethics and Diversity Act
Ohio 2021 HB 110 (FY 2022 budget) Sec 4743.10 pp.1453-1455.
South Carolina 2022 H 4776 Medical Ethics and Diversity Act
Detransition rates are low
Few kids detransition and those who do mostly do so before any medical interventions. Kristina R. Olson, PhD; Lily Durwood, PhD; Rachel Horton, BS; Natalie M. Gallagher, PhD; Aaron Devor, PhD, “Gender Identity 5 Years After Social Transition”, Pediatrics, American Academy of Pediatrics, July 13, 2022
Maria Anna Theodora Catharina van der Loos, MD, Sabine Elisabeth Hannema, PhD, Daniel Tatting Klink, PhD, Prof Martin den Heijer, PhD, Chantal Maria Wiepjes, PhD, “Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands”, The Lancet, October 20, 2022
98% of kids who start blockers and/or HRT as kids continue on them into adulthood Bauer, Sydney, “Transgender Teens Don’t Abandon Hormone Therapy as Adults, Study Finds” The Daily Beast, October 22, 2022 (cites Lancet study above)
Surgical Regret Rates are Low
Surgical regret rates: Bustos, Valeria P.;Bustos, Saymd S;, et al.,Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence Plastic and Reconstructive Surgery Global Open, March 19, 2021
Surgical regret rates: breast augmentation: Isha Sijben, Floyd W. Timmermans, Oren Lapid, Mark-Bram Bouman, Wouter B. van der Sluis, Long-term Follow-up and Trends in Breast Augmentation in 527 Transgender Women and Nonbinary Individuals: A 30-year experience in Amsterdam - Journal of Plastic, Reconstructive & Aesthetic Surgery April 19, 2021
Reduces depression and suicidality
Kerry McGregor Psy.D., John L. McKenna Ph.D., Coleen R. Williams Psy.D., Ellis P. Barrera, Elizabeth R. Boskey Ph.D., M.P.H., M.S.S.W. Association of Pubertal Blockade at Tanner 2/3 With Psychosocial Benefits in Transgender and Gender Diverse Youth at Hormone Readiness Assessment Journal of Adolescent Health, December 13, 2023
Arjee Javellana Restar Gender Affirming Care is Preventative Care The Lancet Regional Health Americas, June 24 2023
Gender confirming care reduces suicidality: Diana M. Tordoff, MPH; Jonathon W. Wanta, MD; Arin Collin, BA; et al,
Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care | Pediatrics | JAMA Network Open February 25 2022; alternate point of access: Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care - PMC
Gender affirming hormone therapy reduces depression and suicidality among trans and non-binary youth: Amy E. Green, Ph.D.; Jonah P. DeChants, Ph.D.; Myeshia N. Price, Ph.D.; Carrie K. Davis, M.S.W:
Association of Gender-Affirming Hormone Therapy With Depression, Thoughts of Suicide, and Attempted Suicide Among Transgender and Nonbinary Youth - Journal of Adolescent Health December 14, 2021
More on gender affirming care & effects on depression and suicidality
Green, Amy E.; DeChants, Jonah P.; Price, Myesha N.; Davis, Carrie K. Association of Gender-Affirming Hormone Therapy With Depression, Thoughts of Suicide, and Attempted Suicide Among Transgender and Nonbinary Youth - Journal of Adolescent Health Journal of Adolescent Health, December 14, 2021
Depression, anxiety, and suicidality rates for trans children whose gender identities are supported are no different than their cis peers:Kristina R. Olson, PhD; Lily Durwood, BA; Madeleine DeMeules, BA; Katie A. McLaughlin, PhD, Mental Health of Transgender Children Who Are Supported in Their Identities, Pediatrics, March, 2016
What does the scholarly research say about the effect of gender transition on transgender well-being?, What We Know, The Public Policy Research Portal, Cornell University. “We conducted a systematic literature review of all peer-reviewed articles published in English between 1991 and June 2017 that assess the effect of gender transition on transgender well-being. We identified 55 studies that consist of primary research on this topic, of which 51 (93%) found that gender transition improves the overall well-being of transgender people, while 4 (7%) report mixed or null findings. We found no studies concluding that gender transition causes overall harm. As an added resource, we separately include 17 additional studies that consist of literature reviews and practitioner guidelines.”
Jack L. Turban, MD, MHS; Dana King, ALM; Jeremi M. Carswell, MD; Alex S. Keuroghlian, MD, MPH, Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation Pediatrics, February 1, 2020.
Puberty Blockers: Experimental? (no) Giordano, Simona; Holm, Soren; Full article: Is puberty delaying treatment ‘experimental treatment’?, International Journal of Transgender Health, April 11, 2020
Serano, Julia Gender-Affirming Care for Trans Youth Is Neither New nor Experimental: A Timeline and Compilation of Studies, May 16, 2023
Gill-Peterson, Jules History of the Transgender Child, University of Minnesota Press, Minneapolis, Minnesota 2018
In the 1960s, Harry Benjamin would routinely demur when minors would write his practice seeking prescription or surgical advice, essentially telling them to wait until they were adults. However, his was not the only perspective of the era.
Hormone therapy for minors
Dr. Lawrence Newman of the Gender Identity Research Clinic at UCLA in the 1960s aimed to use psychotherapy essentially as conversion therapy to make kids as young as five, presenting as trans become cisgender. This typically failed by adolescence and he then began prescribing hormone therapy. Jules Gill-Peterson refers to one such patient, a trans girl who socially transitioned by 15 and whom Newman prescribed hormone therapy at that age. (Gill-Peterson pp. 148-9)
Surgery for minors:
Dr. John Money of the then new Gender Identity Clinic at Johns Hopkins in 1965 successfully lobbied for long term patient, and then criminal defendant G.L. to be a surgical patient for gender affirming surgery while they were 17, under the belief that their accused criminal behavior was due to their “transsexualism” and would cease following such surgery. Delays in parental permission lead to G.L. running away prior to any surgery being realized (Gill-Peterson p. 130)
Dr. Money again in 1973, writing to consult about a 15 year old trans boy, that, he should do a two year real life test before any hysterectomy or ovariectomy, [thus having them around age 17 or 18] but that ‘I am willing to consent to mastectomy much earlier, because it does make occupational adjustment as a male much easier.” and he went on to note the availability of breast implants in case of later regret and recommending starting hormone therapy early. (Gill-Peterson)
Anti-trans legislation harms kids’ increasing depression, etc. Staloch, Laura “The passage of anti-transgender legislation increases internet searches for “suicide” and “depression”, PsyPost, January 23, 2023
More: Novotny, Amy ‘The young people feel it in their bones’: A look at the mental health impact of antitrans legislation The American Psychological Association, June 29, 2023
Thurston, Andrew, How Will Anti-Trans Laws Impact Transgender and Gender-Diverse Youth Mental Health? | The Brink | Boston University March 24, 2023
There have been trans teen boys 16-19 since the late 1960s, recommended by doctors to have masculinizing chest surgeries to help make their social transitions in school easier.
This is not experimental
There are about the same number of elective cosmetic surgeries for cisgender minors per person as medically necessary gender affirming surgeries for trans minors.
Numbers first, then the math, then the sources.
Cisgender teens under 17 years of age have elective, cosmetic plastic surgery procedures at a rate of 25 per 100,000 cis teens per yr
Transgender teens under 17 years of age have medically necessary gender affirming surgeries at a rate of 26 per 100,000 trans teens per yr
The math:
These data are for the U.S. primarily between the years 2019 and 2021.
In 2021, Gallup survey results indicated 2.1 % of the U.S. GenZ population is trans.
The U.S. census indicates that in 2021 the U.S. population of 6-17 year olds was 54.8 million.
With the Gallup data that means about 1.15 million trans GenZ minors between 6-17.
In 2021, there were about 300 gender affirming surgeries trans teens between the ages of 13-17 in the U.S., mostly top surgeries for 17 year old trans boys.
That's 0.026% of trans teens or 26 per 100,000 trans teens per year.
Respaut, Robin and Terhune, Chad, Putting numbers on the rise in children seeking gender care, Reuters, October 6, 2022
Most of the data I could find for cisgender cosmetic surgeries for teens were for teens 13-19, and were around 65,000 annually with an additional 165,000 non-surgical cosmetic procedures.
eg:
2017 Plastic Surgery Statistics Report
For 2019 cisgender cosmetic surgery for teens between 13-17 give numbers closer to 13,400. Those procedures include breast augmentation for girls, breast reduction, rhinoplasty, ear tucks & lipo.
That's about 0.025% or 25 out of 100,000 cis teens
aesthetic plastic surgery national databank - statistics
My total population numbers had included all U.S. kids from 6-17.
Revising to the 13-17 numbers as with the surgery data:
* 1 in 2000 minor cis teens/year have elective cosmetic surgery
* 1 in 2000 minor trans teens/year have gender affirming surgeries, mostly top surgery
Arguments against GAC for minors have included the notion that the brain isn’t fully developed until age 25. This is a misunderstanding.
The myth that the brain is so unfinished in its development prior to age 25 that youth are especially vulnerable to outside influence and poor decision making has been weaponized by the anti-trans movement to extend age restrictions beyond minors.
The Myth of the 25-Year-Old Brain
And it's especially frustrating when sources propagate this notion without understanding the damage that they are inadvertently supporting. (Including Picard Season 3 Episode 9)
Among minors
Respaut, Robin and Terhune, Chad, Putting numbers on the rise in children seeking gender care, Reuters, October 6, 2022
Headline above may be misleading. Even with the reported rise, such numbers after the rise are just reaching being in line with comparable cisgender interventions for that age group including elective cisgender ones.
Comparison for rates among cisgender minors of similar medical interventions
Breast reduction for cisgender male teens with gynecomastia. American Society of Plastic Surgeons: “Briefing Paper: Plastic Surgery for Teenagers”, Connect (Data from 2015)
Social contagion and rapid onset gender dysphoria are bogus:
Serano, Julia, All the Evidence against Transgender Social Contagion. February 13, 2023
Among adults or Among All
Comparison for rates among cisgender people of all ages of similar medical interventions
Among those considered aesthetic plastic surgery
The Aesthetic Society, Aesthetic Plastic Surgery National Databank Statistics 2019
Focus on care of minors
Gill-Peterson, Jules Histories of the Transgender Child, University of Minnesota Press, Minneapolis, Minnesota 2018
Serano, Julia Gender-Affirming Care for Trans Youth Is Neither New nor Experimental: A Timeline and Compilation of Studies, May 16, 2023
Below needs to be sorted:
Summary of concerns of pro- & anti- gender affirming care legislative debate and responses
https://twitter.com/RileyGRoshong/status/1628119645092716544
Webpage for above summary and full 78 page report
Gender-Affirming Care is a human right!
Southern Poverty Law Center’s Project CAPTAIN (first published December 2023) includes sections describing some of the current state of transgender healthcare for minors and adults, along with debunking some of the pseudoscience used to attack gender affirming care through politics and legislation.