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© Reuters. FILE PHOTO: Stickers in the shape of a heart with a trans flag are pictured during a conversation about trans care, equity and access, during National Trans Visibility Month with the Rainbow Room, a program of Planned Parenthood Keystone, in Doylestown, P By Minami Funakoshi and Disha Raychaudhuri

(Reuters) – Lawmakers in 37 U.S. states have introduced at least 142 bills to restrict gender-affirming healthcare for trans and gender-expansive people this year, nearly three times as many as last year.

Four-fifths target gender-affirming care for trans children under 18, while the remainder target adults or anyone regardless of age. Reuters has reviewed the bills, taking stock of where they stand in the approval process, the treatments they seek to restrict and the penalties they would impose.

SB 14

Texas governor Greg Abbott on June 2 signed into law SB 14, which bars transgender children under 18 from receiving hormone therapies and puberty blockers. It goes into effect next month.

Gender-affirming care covers a range of steps to support a person’s gender identity, from adopting a different name and pronouns to counseling. Around the start of adolescence, it can include medical treatment such as puberty blockers, hormones, and later, in some cases, surgery.

Donna Campbell, a Republican Texas state senator and one of the sponsors of SB14, said in April after the legislation passed that it aims to “protect Texas children from harmful, medically unnecessary gender modification treatments.”

SB 14 bans certain procedures only if they are performed for the purpose of “affirm (ing) a person’s perception of his or her sex if that perception is inconsistent with the person’s sex.” A third of the 142 bills introduced this year have such restrictions.

“If you, as the parent of a 16-year-old, want your child to have breast augmentation because she wants a larger bosom and she is a cisgender girl, she can do it,” said Dr. Diana Finkel, associate professor of medicine at Rutgers University Medical School, noting that the law would ban a trans girl from having the same surgery.

In a series last year, Reuters found that the number of children seeking gender-affirming medical care in the form of puberty blockers and hormone treatments has risen sharply in recent years. U.S. clinicians who provide gender-affirming care for minors broadly support medical interventions for adolescents when appropriate. But they also say there is a need for more research on the long-term efficacy and safety of such treatments, Reuters reported.

The World Professional Association for Transgender Health (WPATH), a global body of doctors and other experts specialized in treating trans and gender-diverse people, emphasizes the need for comprehensive assessments of an adolescent’s medical and mental health history to determine whether their gender-affirming care should include medical interventions.

In its most recent guidelines from last September, WPATH also noted that “despite the slowly growing body of evidence supporting the effectiveness of early medical invention, the number of studies is still low” and that there are few studies that follow children into adulthood.

In March, WPATH decried the “broad and sweeping legislation” in many U.S. states seeking to ban access to gender-affirming care and noted that such care covers a wide range of support, not just medical interventions. Such legislation was “in direct contradiction to decades of research and numerous studies touting the overwhelming mental and physical health benefits of gender-affirming care,” WPATH said.

22 BILLS PASSED

Indiana is among the 20 states where legislatures with Republican majorities have banned or restricted gender-affirming care for transgender minors.

The bills are part of a wave of anti-trans legislation, which includes bans on trans girls participating in girls’ sports and measures requiring trans people to use the bathroom corresponding to their sex assigned at birth. Conservative lawmakers have placed gender identity at the heart of a divisive political debate over cultural values, which range from what can be taught in schools to tougher abortion laws.

Many Republican legislators say they want to protect the rights of parents in raising their children and to uphold their religious beliefs, while Democrats say conservatives are undermining public education and targeting vulnerable groups and women’s rights.

Three experts told Reuters that state-level bills are often seen as legislative testing grounds. Language in bills adopted in one state may surface in bills introduced in others or in Congress.

Indiana’s SB 480, signed into law on April 5, establishes a precedent for wide-ranging bans on gender-affirming care, including puberty blockers, hormone therapy and procedures such as:

“augmentation mammoplasty, facial feminization surgery, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation, hair reconstruction, or associated aesthetic procedures” for minors assigned male at birth; and “subcutaneous mastectomy, voice surgery, liposuction, lipofilling, pectoral implants, or associated aesthetic procedures” for minors assigned female at birth.

The law was partially blocked by a federal judge on June 16 following a lawsuit by the American Civil Liberties Union on behalf of four trans minors, their parents and an Indiana physician who provides gender-affirming care. The only part now in effect is the ban on gender-transition surgeries for minors.

The defendants in the lawsuit, which includes members of the Medical Licensing Board of Indiana, appealed the temporary order.

9 BILLS PASSED AT LEAST ONE CHAMBER

Bills that pass one chamber of a state legislature are sent to the other for approval. If a bill passes both chambers, it is sent to the governor who may sign it into law or veto it.

93 BILLS INTRODUCED

Five experts told Reuters that even the introduction of bills seeking to ban gender-affirming care can cause uncertainty within the trans community and deter doctors from providing treatment.

“The mere introduction of these bills sends a message to transgender people in their state that they are not welcome or that there is this organized force that is trying to kick them out of their state,” said Vivian Topping, director of advocacy and civic engagement at Equality Federation, an organization that monitors U.S. state legislation affecting LGBTQ+ communities.

Two sponsors of the bills declined to answer Reuters’ questions on the legislation and its impact. Thirty of them did not respond.

18 BILLS VETOED OR FAILED

Some bills don’t get enough votes to pass both chambers during a legislative session. Bills also fail if a governor vetoes or declines to sign it into law.

RESTRICTING CARE FOR MINORS AND ADULTS

117 of the bills restrict gender-affirming care for trans children under the age of 18. Around 180,000 trans children aged 13-17 live in the states where lawmakers have introduced these bills, according to the Williams Institute, a research center at UCLA’s Law School focused on gender identity law and policy.

Supporters of these bills say they are protecting children who are too young to understand the health impacts of such care.

One side effect in children who take puberty blockers can be a decline in bone density, but this can often be treated with vitamin D or calcium supplements.

“The latest study we have showed that the bone density was back to average for the age after about two or three years of hormone treatment,” said Dr. Ole Petter Hamnvik, an endocrinologist at Brigham and Women’s Hospital. “It is still an area we are actively researching.”

A 2015 review of the effects of hormone therapy on trans people’s fertility found that it may reduce reproductive capability. Those impacts may be reversed if the person stops taking hormones, but the loss of fertility can be permanent in some cases. Trans men can get pregnant and give birth.

The Endocrine Society, a global medical organization devoted to hormone research, says in its guideline for treating gender dysphoria that most adolescents have “sufficient mental capacity to give informed consent” to hormone therapy by age 16.

28 of the bills – or one in five – restrict care for adults or for anyone regardless of age. Nearly 400,000 people above 18 live in states where these bills have been introduced.

WHO IS PROHIBITED FROM PROVIDING OR RECEIVING CARE?

108 of the bills prohibit healthcare providers: Of these bills, 16 ban mental health professionals from providing, assisting, or making referrals for gender-affirming care.

22 bills provide anyone from providing or assisting care: Using broader language, these bills prohibit any “person or entity” from providing or assisting gender-affirming care.

9 apply to parents: Some bills would take away custodial rights of parents who consent to gender-affirming care for their children.

3 bills directly ban trans people from undergoing gender-affirming care: One bill bans trans children under 18 from undergoing gender-affirming care. Two bills — one in Oklahoma and one in South Carolina — ban trans people under 21 from undergoing such care.

The Oklahoma bill says it is “unlawful” for people under 21 to undergo gender-affirming care and that doing so is a felony carrying a minimum three-year prison sentence and maximum of life.

These bills have not yet passed.

EXPOSING PEOPLE TO CIVIL LIABILITY AND CRIMINAL CHARGES

84 of the bills carry civil liability. These bills would make it legal for third parties to sue people who provide or assist gender-affirming care.

“What this is meant to do is essentially incentivize massive amounts of lawsuits that are impossible to stop and to make it impossible for any provider to actually provide this care,” said Alejandra Caraballo, clinical instructor at Harvard Law School.

76 bills suspend or revoke medical licenses: These bills would suspend or revoke licenses of healthcare professionals who provide gender-affirming care.

27 result in a felony charge: These bills would criminalize providing, assisting, or undergoing gender-affirming care. Twenty of them carry sentences ranging from four years to life.

As of publication, Reuters could not find cases where individuals were prosecuted under these laws.

MULTIPLE RESTRICTIONS

Almost 60% of bills contain multiple measures restricting gender-affirming care, from cutting health insurance coverage to revoking medical licenses and criminal charges. Eleven of them have already passed.

Experts in gender-affirming care say the expansive nature of these bills could affect many of the support networks for people who are transitioning.

Florida’s S 254

The bill signed into law by Florida’s Governor Ron DeSantis on May 17 bans gender-affirming care for trans minors and prohibits nonphysicians, such as nurse practitioners, from providing gender-affirming care to trans adults. According to Planned Parenthood, 80% of such care is administered by nurses.

A federal judge issued a preliminary injunction on June 6 that partially blocked this law, allowing three trans children to continue receiving puberty blockers. The state has appealed the injunction.

Thia law would remove custody from parents whose children receive gender-affirming care.

S 254 makes it a felony for healthcare practitioners to provide gender-affirming care for people under 18.

BANNING HEALTH INSURANCE COVERAGE

27 bills across 15 states — 4 of which have passed — would ban Medicaid or publicly funded health plans from covering gender-affirming care. 18 bills across 12 states — only one of which has passed — would ban private health insurers from doing the same.

According to the think tank Movement Advancement Project, Medicaid policies in 26 states and D.C. explicitly cover transition healthcare.

North Carolina’s S 639

This North Carolina bill, introduced in April, prohibits providers receiving state funds from performing gender-affirming care for minors.

It bars government health plans from covering gender-affirming care.

This bill prohibits social workers, therapists and other mental health professionals from providing or “aiding and abetting” gender-affirming care for minors.

EXCEPTIONS TO GENDER-AFFIRMING CARE BANS

Most bills have exceptions to these bans, such as an exceptionally early onset of puberty.

One crucial exception: surgeries for intersex children, who are born with reproductive anatomy, chromosomes, or hormone levels that don’t fit into strict binary understandings of male and female sex.

112 out of the 142 bills explicitly allow pediatric surgeries on intersex children, which more than 30 countries have condemned as “medically unnecessary surgeries” that violate human rights.

Tennessee’s SB 1, which went into effect on April 1, bans doctors from providing gender-affirming care to trans minors and has exceptions for intersex children. In April, the U.S. Justice Department filed a complaint challenging the law, saying it violated the Fourteenth Amendment, which promises equal protection.