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A new law in California protects transgender youth who come for medical care

Lesley McClurg

California is now a sanctuary for transgender youth who come for medical care. A new law protects families traveling from places where there are efforts to criminalize gender-affirming care.

AILSA CHANG, HOST:

A new California law protects families who travel to the state seeking medical care for transgender youth. It's a response to growing efforts in red states against trans rights. Lesley McClurg from member station KQED has more.

LESLEY MCCLURG, BYLINE: After decades of building a life in Texas, a mother suddenly worried she might be investigated for child abuse.

UNIDENTIFIED PERSON: We were stunned that it was no longer safe for us to be there.

MCCLURG: She requested we not use her name because earlier this year, Texas Governor Greg Abbott ordered Family Protective Services to investigate parents with transgender kids. The mother started hearing stories about children who were pulled out of classrooms and interrogated.

UNIDENTIFIED PERSON: With their parents not being there. And these are children that have only socially transitioned. All they asked for was to be called a different pronoun. That's terrifying.

MCCLURG: Her own 12-year-old daughter socially transitioned three years ago, when she asked her family and friends to use feminine pronouns.

UNIDENTIFIED PERSON: And so we sat down and talked to our kid. We gave her a little card to go to school with that listed her rights and told her what to do if somebody came to investigate us.

MCCLURG: But the family could not relax. They sold their home, and this fall they packed up all their belongings and moved to Southern California.

UNIDENTIFIED PERSON: It feels very good to not feel like you're in danger, you know, on that really critical place of, like, our family being ripped apart.

MCCLURG: They feel safe under a new law authored by State Senator Scott Wiener. It ensures families can access hormones or puberty blockers in California. And it shields families from investigations in other states.

SCOTT WIENER: We are going to provide them with refuge, and we're not going to send them back, and we're not going to honor subpoenas. And our law enforcement is not going to enforce the laws of Texas and Alabama criminalizing these families.

MCCLURG: Leaders in 21 states are pushing laws that would restrict medical care for transgender youth. Many of these efforts are tied up in court. Nevertheless, families are panicking because kids who are already on hormones or puberty blockers may lose access to their medication.

GREG BURT: We want these treatments to not be happening on minors because they're permanent.

MCCLURG: Greg Burt is with the conservative Christian California Family Council. He worries kids will regret transitioning.

BURT: We do not assume that your body is the problem. We think it's much more logical to encourage young people to try and get their minds to match their bodies.

MCCLURG: Yet the standard of care for kids who are really distressed and diagnosed with gender dysphoria does include medical interventions. But it's not just the content of the new California law that Burt opposes. He also argues that it violates the Constitution.

JESSICA LEVINSON: There could be litigation both with respect to abortion and with respect to gender-affirming care.

MCCLURG: Jessica Levinson is a professor at Loyola Law School in Los Angeles.

LEVINSON: But I think the weight of the law indicates that states are separate sovereigns. If and until there is a national standard that indicates, nobody can obtain gender-affirming care or nobody can obtain an abortion, the law allows for that patchwork.

MCCLURG: That patchwork is crucial to Kathie Moehlig's work. She is the executive director of Trans Family Support Services in San Diego.

KATHIE MOEHLIG: The politicians should not be making medical decisions for anybody, nor should they be making parental decisions for anybody.

MCCLURG: A survey from the Trevor Project, a suicide prevention organization, found that 45% of transgender youth have considered killing themselves in the last year. About a decade ago, Moehlig helped her 11-year-old access puberty blockers.

MOEHLIG: My son would not still be alive if we waited to 18. He already was in so much distress and so completely miserable. His body was becoming something that he knew he was not.

MCCLURG: Today, she says her son is thriving in college, studying theology. Yet there's little to no data on whether youth who transition regret that decision later. For the Moehlig family, their only regret is waiting as long as they did. For NPR News, I'm Lesley McClurg.

(SOUNDBITE OF OLIVIA RODRIGO SONG, "GOOD 4 U")

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New California law on transgender youths doesn’t remove a parent’s custody

If your time is short.

• A new California law provides legal protections for parents fleeing states that have banned gender-affirming health care for youths.  
• The law clarifies that California courts have jurisdiction over any custody cases that may arise from parents taking their children to the state for care.   
• It doesn’t give the state permission to take custody of a child if one parent disagrees with a child’s decision to seek gender-affirming health care. ​

California Gov. Gavin Newsom recently signed into law a measure that aims to strengthen protections for transgender youths and their families.

Senate Bill 107 contains an array of safeguards for families who arrive in California from states where their children have been denied gender-affirming health care.

It bans courts from enforcing subpoenas from other states regarding minors seeking that care. It prohibits health care providers from releasing medical information. And it clarifies that California courts have jurisdiction over any child custody cases arising from parents taking their children to the state for care.

But a Sept. 29 Facebook post went further to suggest the law says something else: 

"Gov. Gavin Newsom signed Senate Bill 107 into law. In the state of California, your child can now be taken from your custody if you do not affirm gender-reassignment surgery."

The post, shared by the American Council, is a screenshot of a tweet by the group’s founder, Tanner DiBella. The American Council describes itself as an organization dedicated to increasing voter turnout among Christian evangelicals . 

The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed. (Read more about our partnership with Facebook .)

DiBella told PolitiFact the California Legislative Counsel’s summary of the law backs up his reasoning. He pointed specifically to a passage of the summary at the top of bill’s text that reads, "The bill would authorize a court to take temporary jurisdiction because a child has been unable to obtain gender-affirming health care."

But experts we spoke to said that doesn’t mean the state would take custody of the child — it clarifies that California courts would assume jurisdiction of the legal matter. Current law allows California courts to decline jurisdiction in multistate custody matters in certain circumstances.

Courtney Joslin, a Martin Luther King Jr. professor of law at the University of California, Davis School of Law, said the law has nothing to do with who gets custody of a child during a dispute and makes no mention of allowing the court to take custody.

"It’s just describing which courts have jurisdiction in those multi-state (custody disputes)," she said. "There’s no possibility that this bill could be interpreted to do what this person is claiming."

Asaf Orr, a senior staff attorney and Transgender Youth Project director at the National Center for Lesbian Rights, said the bill doesn’t give California carte blanche to remove a child from a parent’s custody. 

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If parents disagree over whether their child should receive gender-affirming care in California, a state court would hear that case and rule based on evidence provided by both parents, Orr said. Out-of-state laws would not apply to the court’s determination. 

Orr said this isn't a new thing, as a state already has jurisdiction over court cases related to children who recently entered that state, for reasons such as escaping from domestic violence. 

"It just ensures that, in situations like this, the court recognizes they have jurisdiction to hear these cases and that they’re going to decide them based on the evidence," he said. "Both parties, as in any court case, will have the opportunity to present evidence and it’s going to be individualized for that young person."

Wendy Seiden, a visiting professor at Chapman University’s Fowler School of Law, said there is nothing in the law that would allow California to take custody of a child. But it does allow California to resist another state’s attempt to remove a parent’s custody if the proposed removal is based on that parent’s efforts to get gender-affirming care for their child.

California state Sen. Scott Wiener, D-San Francisco, an attorney and Senate Bill 170’s author, described DiBella’s interpretation of the text as "categorically false."

"It doesn’t change custody laws in any way," Wiener said. "It just means that, rather than having to go back to Texas or Alabama, they can do it in court here." 

Weiner said he authored the bill in response to proposed legislation in other states involving transgender youth. It provides guidance, he said, for California courts concerning custody hearings involving transgender youths and it helps protect parents who decide to bring their children to the state.

"This bill literally protects parents’ ability to make decisions about children's health care without having to be thrown in prison," Wiener said.

At least 24 states have proposed bills since Jan. 1 targeting transgender or nonbinary youths’ ability to receive gender-affirming care.  

In Texas, Republican Gov. Greg Abbott issued a directive earlier this year that ordered state officials to launch child abuse investigations of parents suspected of allowing their child to receive gender-affirming care. 

Alabama Gov. Kay Ivey signed a law in April that makes providing gender-affirming care for youths a felony, punishable by up to 10 years in prison.

A Facebook post claims that a recently signed California law dealing with gender-affirming care for transgender youth will allow that state to take custody of a child from a parent. 

Experts said that’s not so. The bill clarifies that California courts have jurisdiction to hear any custody cases related to a child being taken to the state to seek gender-affirming health care. It does not say that the courts can take custody of a child. 

We rate this claim False.  

Our Sources

Facebook post ( archive ), Sept. 29, 2022

Twitter post ( archive ), Sept. 29, 2022

Office of California Gov. Gavin Newsom, SB 107 Signing , Sept. 29, 2022

California Legislature, Senate Bill No. 107 , Oct. 3, 2022

The American Council, About , accessed Oct. 3, 2022

Email with Tanner DiBella, Oct. 3, 2022

Phone interview with Courtney Joslin, Oct. 10, 2022

Phone interview with Asaf Orr, Oct. 3, 2022

Email with Wendy Seiden, Oct. 8, 2022

Phone interview with California State Sen. Scott Wiener, Oct. 3, 2022

The Los Angeles Times, "Newsom signs bill protecting transgender youths and families fleeing red-state policies," Sept. 29, 2022

Bloomberg Law, "Transgender Health Care Becomes Target for Wide GOP-Led Rollback," Sept. 20, 2022

The Texas Tribune, "Transgender Texas kids are terrified after governor orders that parents be investigated for child abuse," Feb. 28, 2022

NBC News, "Alabama ban on gender-affirming care for transgender youth takes effect," May 9, 2022

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California Becomes First Sanctuary State for Transgender Youth Seeking Medical Care

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California is the first state in the nation to create a sanctuary for transgender youth seeking gender-affirming medical care. Gov. Gavin Newsom signed a new law in September that ensures transgender kids from elsewhere can safely access hormones or puberty blockers here. The legislation also shields families from child abuse investigations or from being criminally prosecuted for seeking gender-affirming care.

“In California we believe in equality and acceptance. We believe that no one should be prosecuted or persecuted for getting the care they need — including gender-affirming care,” Newsom said in a signing message . “Parents know what’s best for their kids, and they should be able to make decisions around the health of their children without fear. We must take a stand for parental choice.”

This year a wave of bills in states ranging from New Hampshire to Arizona have attempted to limit, ban or criminalize access to medical care for transgender and nonbinary youth. An Alabama law passed in February not only banned medication for transgender youth, but ruled that doctors who break it could face up to 10 years in prison.

“You don’t disfigure 10-, 12-, 13-year-old kids based on gender dysphoria,” Florida Gov. Ron DeSantis said at an August press conference . “I think these doctors need to get sued for what’s happening.”

Most of these laws are in legal limbo as they are challenged in court . Meanwhile, families are panicking.

Scared out of Texas

After decades of building a life in Texas, a mother of a 12-year-old suddenly worried she might be investigated for child abuse, after Gov. Greg Abbott ordered the Texas Department of Family Protective Services to investigate parents who are providing gender-affirming care to their kids last February.

“We were stunned that it was no longer safe for us to be there,” said the mother, who asked that KQED not use her name to protect her identity and that of her child.

Even after a Texas judge temporarily stayed such investigations , Texas Attorney General Ken Paxton insisted that they were legal and would continue .

Media reports soon detailed experiences where state investigators pulled trans youth out of classrooms for interrogations.

“With their parents not being there,” said the Texas mother, adding that she heard similar stories from family friends. “And these are children that have only socially transitioned. All they asked for was to be called a different pronoun. That's terrifying.”

Three years ago, her own 12-year-old daughter asked her friends and family to use feminine pronouns.

“And so we sat down and talked to our kid,” she said. “We gave her a little card to go to school with that listed her rights and told her what to do if somebody came to investigate us.”

But the family could not relax. They said they had no choice but to sell their home. This fall they packed up all of their belongings and moved to Southern California.

“It feels very good to not feel like you're in danger — in that really critical place of our family being ripped apart,” said the mother.

Providing refuge

They feel safe under a new law authored by state Senator Scott Wiener (D-San Francisco), which declares that any potential out-of-state arrest warrant for violating laws related to such care will be given “the lowest law enforcement priority.”

“We are going to provide them with refuge and we're not going to send them back and we're not going to honor subpoenas,” said Sen. Wiener. “And our law enforcement is not going to enforce the laws of Texas and Alabama criminalizing these families.”

High stakes

Mental health therapists say puberty blockers and hormone therapy can save lives . A recent survey found that nearly 1 in 5 transgender 13- to 24-year-olds have attempted suicide in the past year.

The World Health Organization defines gender-affirming care as a variety of “social, psychological, behavioral and medical interventions designed to support and affirm an individual’s gender identity.”

These interventions can be nonmedical — called social transitioning — like when a child adopts a chosen name and/or new pronouns or dresses in alignment with their gender identity. Research suggests changing one's name may reduce depression and suicide ideation.

Also, beginning in early adolescence, doctors may prescribe medical interventions. The World Professional Association for Transgender Health recommends waiting until youth are 15 years old for surgical procedures, according to their new guidance released over the summer.

Constitutional questions

The new California law faces fierce opposition. Forty-five organizations, including the Alliance Defending Freedom and  The Heritage Foundation , penned a letter to Newsom urging him to veto Wiener’s bill.

“We want these treatments to not be happening on minors because they're permanent,” said Greg Burt, director of capitol engagement for the California Family Council , a Christian faith-based organization. “We do not assume that your body is the problem. We think it's much more logical to encourage young people to try and get their minds to match their bodies.”

Yet the standard of care for kids who are really distressed and diagnosed with gender dysphoria does include medical interventions.

California is also acting as a sanctuary for those individuals seeking abortions from other states after the U.S. Supreme Court overturned Roe v. Wade, the historic 1973 ruling that granted a legal right to the procedure. But conservatives, including Burt, argue that California’s “sanctuary” laws on abortion and gender-affirming care violate the Constitution.

“There's going to be a constitutional crisis if states don't honor each other's civil judgments,” Burt said.

Jessica Levinson, professor at Loyola Law School in Los Angeles, said there “could be litigation both with respect to abortion and with respect to gender-affirming care.”

But she and other legal experts are not convinced by conservative critiques that the new California laws violate the Constitution’s full faith and credit clause .

“I think the weight of the law indicates that states are separate sovereigns. If and until there is a national standard that indicates nobody can obtain gender-affirming care or nobody can obtain an abortion, the law allows for a patchwork,” Levinson said.

That patchwork is crucial to the families seeking help at Trans Family Support Services in San Diego.

“The politicians should not be making medical decisions for anybody, nor should they be making parental decisions for anybody,” said Kathie Moehlig, the organization’s executive director.

About a decade ago, Moehlig helped her 11-year-old access puberty blockers.

“My son would not still be alive if we waited until 18,” she said. “He already was in so much distress and so completely miserable that his body was becoming something that he knew he was not.”

Today she says her son is thriving in college, studying theology. He has never regretted transitioning.

There is no solid data on how many kids remain satisfied with medical interventions, or feel remorse about gender-affirming transitions. A recent report from Reuters highlights the lack of solid evidence on the long-term effects of gender-affirming care . For example, there is very little known about how transitioning affects fertility or cognitive development. Puberty blockers and sex hormones do not have FDA approval for children’s gender care, and the National Institutes of Health has said that clinical trials have not yet determined whether there are any short- or long-term health risks for teens.

For the Moehlig family, their only regret is that they waited as long as they did to transition their son.

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A.G. File No. 2023-020

Pursuant to Elections Code Section 9005, we have reviewed the proposed measure (A.G. File No. 23-0020, Amendment #1) related to certain gender-affirming medical procedures for individuals under the age of 18 years.

Some Children Are Transgender. Sex generally refers to a person being biologically male, female, or intersex. The attitudes, feelings, and behaviors that a given culture associates with these biological designations are generally known as gender. Gender identity generally refers to an individual’s internal sense of being male, female, or something else. For example, transgender individuals have gender identities that differ from the sex assigned to them at birth.

Transgender Children Are a Small Share of California’s Population. Data on transgender individuals are limited. That said, research suggests that transgender individuals comprise a small share of children. For example, one recent study by the Williams Institute at the University of California, Los Angeles estimates that nearly 50,000 individuals (around 2 percent) of individuals between the age of 13 to 17 years identify as transgender in California.

Some Transgender Children Receive Health Care Services to Affirm Their Gender Identity. Some transgender individuals experience distress from having a gender identity that is different from their sex assigned to them at birth. Transgender individuals experiencing distress can receive certain health care services, including mental health services and medical treatments. These treatments can be a part of what is referred to as “gender affirming care.” Medical treatments can include prescription drugs to postpone the development of puberty (known as “puberty blockers”), hormone therapies, and surgeries. For transgender children, decisions around which treatment to provide and when to provide the treatment are made jointly by the physician and parent of the child, generally following professionally recognized standards.

California Law Protects Access to Gender-Affirming Care. A number of laws in California protect access to gender-affirming care for transgender individuals. For example, California law prohibits health insurance plans from discriminating against transgender patients, including by denying patients access to gender-affirming treatments when the treatments are medically necessary.

California Helps Pay for Health Care for Many Individuals, Including Gender Affirming Care. State and local governments help certain Californians pay for health care through a number of different programs. For example, Medicaid, known as “Medi-Cal” in California, provides health coverage to eligible low-income California residents. It is funded from a mix of federal, state, and local funds. Health care services covered by Medi-Cal include gender affirming care for transgender individuals, generally when considered to be medically necessary.

California Licenses Health Care Providers. California law requires health insurance plans, health care providers, and health care facilities to be licensed to provide health care services. Several departments are responsible for licensing health care entities in California. For example, the Department of Consumer Affairs includes numerous licensing boards that license health care providers, such as physicians, nurses, and pharmacists, among others. These departments and boards generally cover the cost to license providers and investigate complaints by charging affected providers fees and fines.

Prohibits Providing Certain Medical Treatments That Affirm a Different Gender Than Biological Sex for Youth. The measure would prohibit health care providers (such as a physician or a nurse) from providing patients under the age of 18 certain medical treatments that affirm a gender identity different than the patient’s biological sex. The initiative specifically would prohibit prescribing or administering puberty blockers, hormones or hormone antagonists, and surgery or medical procedures. The measure defines biological sex as either male or female, based on specified physiological and genetic attributes.

Excludes Three Kinds of Services From Prohibitions. The measure would exclude from these prohibitions the following: (1) services medically necessary to treat a minor born with a medically verifiable genetic disorder of sexual development; (2) services to return a child who previously received gender-affirming procedures back to his or her biological sex; and (3) services to children who began gender-affirming procedures prior to when the measure becomes law or January 1, 2025, whichever is earlier.

Enacts Consequences to Providers for Providing Services. Except for the exclusions described in the previous paragraph, providing a prohibited medical service under the measure would be considered unprofessional conduct and subject to discipline and a hearing process by the provider’s licensing entity. The measure specifies that such discipline would include revoking of the health care provider’s license or certification.

Fiscal Effect

Impact Depends on Court Rulings Related to Gender-Affirming Health Care. In recent years, several states have enacted prohibitions on health care providers from providing certain gender-affirming medical treatments, including treatments that would be prohibited under this measure. Many of these laws are being litigated in the federal court system to determine whether they conflict with the United States Constitution. At the time of this analysis, the courts have allowed bans in some states to take effect, while bans in other states have not been allowed to go into effect. If a court were to rule this measure could not go into effect, it would have no fiscal effect. Alternatively, were the measure to withstand legal challenges, there would be fiscal effects, described below.

If Measure Becomes Law, Possible Minor Savings From No Longer Covering Prohibited Treatments… Were the measure to become law, state and local government health programs that pay for gender-affirming puberty blockers, hormone therapies, and surgeries for youth could no longer do so. Although comprehensive data on state and local government spending for these services is not available, it could be as much as in the millions of dollars annually. This represents a very small share of overall state and local spending, with the state General Fund providing $37.5 billion to Medi-Cal in 2023-24, for example.

…Could Be Impacted by Other Long-Term Effects. The savings from no longer paying for health care services could be increased, reduced, or even offset by other health-related impacts. For example, some Medi-Cal enrollees under the age of 18 who otherwise would have received prohibited services may choose to receive some of these services when they are adults. In these cases, some of the spending associated with prohibited services would still occur, but at a later time for the individual. In other cases, individuals who are eligible for Medi-Cal as children may earn too much income to qualify for Medi-Cal as adults or forgo these services altogether. These effects are difficult to project. Also adding to the fiscal uncertainty, the long-term effects on mental and physical health of providing gender-affirming care to transgender youth are actively being studied. Depending on these long-term impacts, prohibiting certain gender-affirming medical treatments on individuals under the age of 18 could affect the use of health care services, with corresponding fiscal impacts

Potential, but Unknown, Cost Pressure Related to Federal Anti-Discrimination Laws. Federal law prohibits health care providers that receive federal funding for health programs (such as Medicaid) from discriminating against patients on the basis of race, sex, and other factors. Federal courts currently are assessing whether these nondiscrimination provisions extend to gender identity and the provision of gender-affirming care. Depending on the decisions in these court cases and any resulting federal actions, California providers could face a number of potential consequences, including revoked federal funding. Such actions also could place pressure on state and local governments to backfill lost federal funding. Whether action is taken and the magnitude of such action is unknown, but the impact could be significant.

Summary of Fiscal Effects. We estimate the measure would have the following fiscal effects:

• To the extent the measure can be legally implemented, potentially relatively minor savings up to the millions of dollars annually from no longer paying for prohibited services for individuals under the age of 18. These savings could be affected by many other impacts, such as individuals seeking treatment later in life.
• Potential, but unknown, cost pressure to state and local governments related to federal fiscal penalties if the measure results in providers being deemed out of compliance with federal law.

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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

Trans kids’ treatment can start younger, new guidelines say

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Assn. for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association, known as WPATH, provided an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

World & Nation

A transgender psychologist has helped hundreds of teens transition. But rising numbers have her concerned

Erica Anderson took more than half a century to come out as a woman. Now she works with teens in a rush to transition.

April 12, 2022

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of WPATH last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.”

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number probably reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,” she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.”

Op-Ed: Denying trans youth gender-affirming care is an affront to science and medical ethics

States are pushing anti-trans policies that fly in the face of research and medical expertise.

June 13, 2022

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, N.C., resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,” he said. “I’m so much happier now.”

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,” they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.”

Science & Medicine

Early transgender identity in kids tends to endure, study suggests

Children who begin identifying as transgender at a young age tend to retain that identity for several years at least, a new study suggests.

May 4, 2022

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,” Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

• Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

• Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum age wasn’t listed.

• Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Assn. support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader , a Northwestern University pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams , a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

More to Read

Some states are trying to make sex binary. Transgender people see their existence denied

Feb. 28, 2024

Ohio is poised to become the 2nd state to restrict gender-affirming care for adults

Jan. 20, 2024

Editorial: Want to protect children? Don’t sign this trans-bashing petition

Dec. 10, 2023

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March 31, 2024

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California set to become a refuge for transgender health care

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Lawmakers approved a bill to protect those receiving or providing transgender health care in California from prosecution under a wave of legislation in other states. But the proposal drew intense opposition from the California Family Council. Gov. Gavin Newsom signed the bill.

Lea este artículo en español .

Update: Gov. Gavin Newsom announced Sept. 29 he signed the bill, issuing a statement that said in part: “In California we believe in equality and acceptance. We believe that no one should be prosecuted or persecuted for getting the care they need — including gender-affirming care.”

When Kathie Moehlig’s 11-year-old son decided to transition in 2012, she says not one doctor in San Diego was willing to treat him. “When I called to make appointments, they kept telling me: ‘We don’t treat kids like that here,’” Moehlig said.

But she continued making calls, eventually breaking through at Rady Children’s Hospital. Her efforts drew attention from other families of transgender kids, many of whom began asking her for help. 

She decided she “couldn’t just be a family friend,” so eight years ago she started TransFamily Support Services , a nonprofit that offers a multitude of services to hundreds of families of transgender individuals across the country, including support groups, assistance navigating the medical system, and — most recently — political advocacy. 

Now, TransFamily Support Services is a co-sponsor of Senate Bill 107 , designed to protect from prosecution patients who travel to California for what supporters call gender-affirming care and doctors who provide that care.

The Assembly gave its final approval to the bill in a 60-19 vote . The Senate went along on a 30-9 vote, sending the bill to Gov. Gavin Newsom, who signed it Sept. 29.

The bill will make California a refuge for minors seeking gender-affirming care , similar to how Assembly Bill 1666 , which Newsom signed into law in June , made the state a refuge for those seeking abortions.

“It will send a very clear message that trans kids and their families, if they don’t feel safe in their state, they can come here and we’ll do everything in our power to protect them from prosecution,” state Sen. Scott Wiener, a San Francisco Democrat and the bill’s author, told CalMatters.

But state Sen. Melissa Melendez, a Lake Elsinore Republican, said the bill interferes with the relationship between parents and their transgender children.

“I don’t disagree that we should make sure that kids in this category are protected, and not bullied, and not harassed, and provided some understanding and certainly any medical attention mental-health-wise that they may need,” she said during the floor debate. “But I don’t think the state of California should be stepping in and facilitating that. That’s not our place.”

In a statement in response to the bill signing, Jonathan Keller, president of the California Family Council, said: “By signing this extreme bill, Gavin Newsom is telling all parents across the country that he knows what’s best for their children.”

But Tony Hoang, executive director of Equality California, countered in a statement: “While small, hateful men like Greg Abbott and Ron DeSantis attack trans children and their families, Governor Newsom today made clear that California will welcome them with open arms. SB 107 officially makes California a state of refuge for trans kids and their families.”

A national wave   

The bill, perhaps the highest profile of several LGBTQ-related proposals also signed by Newsom, responds to a recent wave of legislation: At least 40 bills in 20 states would restrict access to gender-affirming medical care for transgender youth. These proposals vary from an Idaho bill to criminalize gender-affirming medical procedures to a Florida law banning their insurance coverage . In Texas, state social workers are reportedly rebelling — or even threatening to quit — rather than carry out an order by Gov. Greg Abbott to investigate parents who allow transgender health care.

Proponents of the bill say it is California’s responsibility to intervene.

“There are efforts all across the country…to go after trans kids and their families. California has a role to play in providing a safe, welcoming environment for trans kids and their families to get the care they need,” said Samuel Garrett-Pate, managing director of external affairs for Equality California, which supports the bill and says it’s the nation’s largest LGBTQ civil rights group.  

SB 107 would: 

• Prohibit law enforcement participation and the arrest or extradition of an individual for allowing a person to receive or provide gender-affirming care when that care is legal under California and federal law. 
• Declare arrest warrants for individuals who allowed their child to receive gender affirming health care the lowest law enforcement priority.
• Ban the enforcement of another state’s law authorizing a state agency to remove a child from their parent or guardian because they allowed their child to receive gender-affirming care.
• Bar compliance with subpoenas seeking medical information related to gender-affirming care that interferes with a person’s right to allow a child to receive that care.

“As it stands, transgender youth and their parents in these states are under a constant threat of being reported by anyone around them, while foregoing life-saving treatment,” said Assemblymember Lori Wilson, a Suisun City Democrat and parent of a trans person, in presenting the bill on the Assembly floor. “In doing so, they are targeting our most vulnerable population — children — as well as their parents and doctors who support them.”

Learn more about legislators mentioned in this story

Scott Wiener

State Senate, District 11 (San Francisco)

Time in office

2016—present

Member, Board of Supervisors

Email Legislator

Race/Ethnicity

Voter Registration

Sen. Scott Wiener has taken at least $834,000 from the Finance, Insurance & Real Estate sector since he was elected to the legislature. That represents 14% of his total campaign contributions.

Lori Wilson

State Assembly, District 11 (Suisun City)

2022—present

Mayor / Finance Director

Asm. Lori Wilson has taken at least $379,000 from the Labor sector since she was elected to the legislature. That represents 24% of her total campaign contributions.

Foes raise concerns

By leaning into the national debate around transgender issues, the bill has generated intense opposition. 

Opponents say that children often misunderstand their gender identity and are likely to regret their decision to get irreversible treatments such as hormone replacement therapy and gender-affirming surgery.

“A lot of kids don’t quite comprehend the implications of taking puberty blockers, cross-sex hormones and even some of the surgeries; don’t comprehend the long-term nature and the damaging effect it would have on their on their bodies when they were minors,” said Greg Burt, a spokesperson for the California Family Council .

Burt cited testimony from Chloe Cole before the Assembly Public Safety Committee on June 28. 

“SB 107 is circumventing states’ laws and that have needed safeguards in place so my story’s not repeated. Children cannot consent,” said Cole, a 17-year-old from the Central Valley, who medically transitioned from age 13 to 15 with puberty blockers, male hormones and a mastectomy. 

Given this, Burt said the religious nonprofit “would be against any kind of drugs or surgeries to try and match a person’s body to their feelings below the age of 18,” regardless of parental consent.

“We don’t let parents sterilize their kids, even if parents consent to it, and we think this is in the same category,” Burt said. “You can’t harm your child permanently, even if you believe the harm is somehow justified.”

However, Sen. Richard Pan, a Sacramento Democrat who is also a pediatrician, said the medical profession does not recommend surgery for transgender individuals under the age of 18. During the floor debate on Wednesday, he cited research showing that the majority of children who question their gender identity do not change their minds and that the majority of treatments provided to transgender youth are reversible.

Opponents also highlight a clause in the bill that they say could take custody rights away from an out-of-state parent who disagrees with the other on their child’s gender-affirming care.

Erin Friday, a San Francisco attorney and parent of a child who once wanted to transition, said that the clause “pits parents against parents” by allowing an out-of-state parent to refile for full medical custody of their child in California and eclipse the consent of the non-affirming parent.

“It makes it easier for the one parent who wants to harm their child to harm their child, and it’s an enticement for kids to run away. There’s no two ways about it,” she said.

Wiener’s office disputes that this is the bill’s intent .

“The point of the bill is not to remove kids from their parents’ custody — not when parents come here with their kids to prevent states like Texas from removing them from their custody,” he said.

Helping families, one at a time

As the political debate rages on, Moehlig and her staff of 10 continue their work, helping families across America figure out the best doctor and how to get insurance coverage, and providing support groups for people from elementary school to age 30. She says her group has assisted 3,000 families in its lifetime.

That work convinces her of the importance of the bill. She said it’s “ludicrous” for politicians to assert that they know better than the parents of transgender children and their doctors about what medical care and treatment is best.     

As of now, every law that criminalizes gender-affirming care in other states has been delayed by legal challenges. Moehlig, however, said it’s only a matter of time before one of these bills becomes law.

And she’s already seeing the impact: She said she has multiple clients who have moved to California because of the laws in other states. One of her clients in Texas said his doctor canceled his female-to-male top surgery because they were no longer comfortable treating transgender youth.

“I think that protecting the rights of these parents to make these medical choices and get this treatment for these kids without having to worry about any of the ramifications of prosecutions is super important,” Moehlig said.

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Ariel Gans was a political reporting intern focusing on the 2022 election cycle. She recently got her master’s of journalism from Northwestern University, where she specialized in politics, policy, and... More by Ariel Gans

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California governor signs bill offering legal refuge to transgender youths 

California Gov. Gavin Newsom signed a bill Thursday that aims to legally protect transgender youths and their parents if they flee conservative states that have restricted access to gender-affirming care. 

The bill seeks to “offer refuge” to trans minors and their families “if they’re being criminalized in their home states,” state Sen. Scott Wiener, who introduced the bill, said on Twitter after Newsom signed it.

Wiener said states like Texas and Alabama “are seeking to tear these families apart,” referring to efforts in both states to bar parents from providing their trans children with medical care like puberty blockers and hormone therapy.

In February, Texas Gov. Greg Abbott called on the state’s Department of Family and Protective Services to “conduct a prompt and thorough investigation” of any reported instances of minors undergoing “elective procedures for gender transitioning.” He also encouraged anyone who works with children in the state and regular citizens to report parents providing such care. 

Following the directive, the department confirmed that it opened at least nine investigations , but state courts have since blocked most of those investigations .

In Alabama, Gov. Kay Ivey signed a bill that makes it a felony for medical professionals to provide gender-affirming medical care to people under 19. 

“We should especially protect our children from these radical, life-altering drugs and surgeries when they are at such a vulnerable stage in life,” Ivey said in a statement at the time.

A judge partially blocked enforcement of that law in May.

Tennessee also passed a law prohibiting gender-affirming care for prepubertal youth , though advocates said at the time that there were no doctors in the state who provided transition care to children prior to puberty.

As a result of the policies, some families of transgender minors have decided to leave their home states so they can continue to access gender-affirming care, which is supported by accredited medical groups — including the American Medical Association , American Academy of Pediatrics and American Psychological Association .

The bill Newsom signed is intended to protect families and children like those from prosecution in their home states if they travel to California for gender-affirming care or if they move to California after already receiving transition-related care elsewhere. 

“We believe that no one should be prosecuted or persecuted for getting the care they need — including gender-affirming care,” Newsom said in a statement after signing the measure. “With the signing of this bill, California will ensure that these kids and their families can seek and obtain the medical and mental health care that they need.”

The legislation includes a variety of provisions that are meant to help protect families and trans kids. It prohibits California health care providers from releasing medical information in relation to other states’ laws prohibiting gender-affirming care for minors. It also prohibits the enforcement of a court order “based on another state’s law authorizing a child to be removed from their parent or guardian based on that parent or guardian allowing their child to receive gender-affirming health care or gender-affirming mental health care.”

The bill also authorizes a California court to take temporary emergency jurisdiction when a child hasn’t been able to receive gender-affirming health care elsewhere, which some on social media interpreted to mean that California courts will be able to take custody of children if they flee their home states because their parents don’t want to provide them with gender-affirming care. 

But that isn’t accurate, according to Asaf Orr, a senior staff attorney and Transgender Youth Project director at the National Center for Lesbian Rights. Orr said that portion of the bill is related to a court’s jurisdiction in custody matters. 

“State courts around the country have the authority to consider whether to retain jurisdiction over a custody matter involving a child who recently came into the state,” Orr told Reuters . “This typically occurs in instances of domestic violence or other crisis situations. This law simply clarifies that courts should retain jurisdiction in situations where a parent brings their child to California so that they can obtain medical treatment for gender dysphoria.” Gender dysphoria is a medical condition that involves a conflict between an individual’s sex assigned at birth and their gender identity. 

Follow  NBC Out  on  Twitter ,  Facebook  &  Instagram

Jo Yurcaba is a reporter for NBC Out.

The independent source for health policy research, polling, and news.

Youth Access to Gender Affirming Care: The Federal and State Policy Landscape

Lindsey Dawson , Jennifer Kates , and MaryBeth Musumeci Published: Jun 01, 2022

This analysis reflects the policy environment as of June 2020. Our newer tracker , provides a regularly updated overview of state policy restrictions on youth access to gender affirming care.

Numerous states have implemented or considered actions aimed at limiting LGBTQ+ youth access to gender affirming health care. Four states (Alabama, Arkansas, Texas, and Arizona) have recently enacted such restrictions (though the AL, AR, and TX laws all have been temporarily blocked by court rulings) and in 2022, 15 states are considering 25 similar pieces of legislation. At the same time, other states have adopted broad nondiscrimination health protections based on gender identity and sexual orientation. Separately, the Biden administration, which has been working to eliminate barriers and expand access to health care for LGBTQ+ people more generally, has come out against restrictive state policies. This analysis explores the current state and federal policy landscape regarding gender affirming services for youth and the implications of restrictive state laws.

What is the status of state policy restrictions aimed at limiting youth access to gender affirming care?

Four states (Alabama, Arkansas, Texas, and Arizona) recently enacted laws or policies restricting youth access to gender affirming care and, in some cases, imposing penalties on adults facilitating access. Alabama, Arkansas, and Texas have been temporarily blocked from enforcing these laws and policies by court order.

• Alabama. In April 2022, the Alabama governor signed a bill into law that prevents transgender minors from receiving gender affirming care, including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a felony for any person to “engage in or cause” a transgender minor to receive any of these treatments, punishable by up to 10 years in prison or a fine up to $15,000. The bill additionally states that nurses, counselors, teachers, principals, and other administrative school officials shall not withhold from a minor’s parents or guardian that their child’s “perception of his or her gender or sex is inconsistent with the minor’s sex” assigned at birth and shall not encourage a minor to do so. Shortly after enactment, a federal lawsuit challenging the law was filed by four Alabama families with transgender children, two healthcare providers, and a clergy member. Subsequently, the U.S. Department of Justice (DOJ) joined the case as an additional plaintiff challenging the law. This case has been consolidated with another lawsuit filed by two other Alabama families with transgender children, which raises similar challenges. In May 2022, a federal district court entered a preliminary injunction, blocking enforcement of several sections of the Alabama law while the litigation is pending. Specifically, the preliminary injunction applies to the sections of the law that prohibit puberty blockers and hormone therapy. Other sections of the law remain in effect, including the prohibition on surgical intervention and the prohibition on school officials keeping secret or encouraging or compelling children to keep secret certain gender-identity information from children’s parents. When deciding to grant the preliminary injunction, the district court found that the plaintiffs were substantially likely to succeed on their claim that the sections of the law that prohibit puberty blockers and hormone therapy unconstitutionally violate parents’ fundamental right to autonomy under the 14 th Amendment’s due process clause by prohibiting parents from obtaining medical treatment for their children subject to medically accepted standards. The court also fond that the plaintiffs were substantially likely to succeed on their claim that these sections of the law are unconstitutional sex discrimination in violation of the 14 th Amendment’s equal protection clause because the law denies medically necessary services only to transgender minors, while allowing those services for cisgender minors. Additionally, the court found that the plaintiffs were likely to suffer irreparable harm, in the form of “severe physical and/or psychological harm” and “significant deterioration in their familial relationships and educational performance,” if the law was not blocked. The state has appealed the district court’s decision to the 11 th Circuit.
• Arkansas . In 2021, on override of Governor Hutchinson’s veto, Arkansas lawmakers passed legislation prohibiting gender-affirming treatment for minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law also prohibits medical providers from making referrals to other providers for minors seeking these procedures. Under the law, medical providers offering gender affirming care or providing referrals for such care to minors may be subject to discipline by relevant licensing entities. The legislation additionally includes a prohibition on private insurance coverage of gender affirming services for minors and a prohibition on the use of public funds, including through Medicaid, for coverage of these services for minors. In May 2021, four families of transgender youth and two physicians challenged the Arkansas law in federal court, arguing that the law is illegal sex discrimination under the 14 th Amendment’s equal protection clause. They also argue that the law violates parents’ right to autonomy protected by the 14 th Amendment’s due process clause and violates the families and physicians’ right to free speech under the 1 st Amendment. The U.S. Department of Justice (DOJ) filed a statement of interest in support of the plaintiffs’ motion for a preliminary injunction in the Arkansas case. DOJ  argued that the Arkansas law  violates the Equal Protection Clause of the 14 th Amendment because the state law “singles out transgender minors. . . specifically and discriminatorily den[ies] their access to medically necessary care based solely on their sex assigned at birth.” A preliminary injunction was granted in July 2021, temporarily blocking the state from enforcing the law while the case is pending. The court found that the plaintiffs were likely to succeed on all three of their Constitutional claims, and that the law was not substantially related to the state’s interest in protecting children or regulating physicians’ ethics because the law allows the same medical treatments for cisgender minors. The court also found that the plaintiffs will suffer irreparable physical and psychological harm if the law is not blocked. The court also denied the state’s motion to dismiss the case. The state has appealed both of those decisions to the 8 th Circuit, where a decision is currently pending. A group of 19 states filed an amicus brief in support of the state’s appeal. 1 They argue that states have “broad authority” to regulate gender affirming services, because they allege this area is “fraught with medical uncertainties,” contrary to the evidence from the American Academy of Pediatrics and the American Medical Association on which the lower court relied. Another group of 20 states and the District of Columbia filed an amicus brief in support of the plaintiffs. 2 They argue that they and their residents are economically, physically, and mentally harmed by discrimination against transgender people. They also argue that their states “protect access to gender-affirming healthcare based on well-accepted medical standards” and that Arkansas’ law is unconstitutional sex discrimination and “ignores medical consensus as well as decisions made between doctors and their patients.” Litigation in the case continues in the district court, where the case is scheduled for trial during the week of July 25, 2022.
• Texas . In February 2022, Governor Abbott of Texas issued a directive defining certain gender affirming services for youth as child abuse, and calling for investigation of and penalties for parents who support their children in taking certain medications or undertaking certain procedures, which could include the removal of their children. In addition, under the directive, health care professionals who facilitate access to these services could also face penalties and a range of professionals in the state would be mandated to report known use of the specified gender affirming services. While other states with proposed policies to limit youth access to gender affirming care include penalties for parents who facilitate access to these services (see below), no implemented policy ties the parental role to child abuse as the Texas directive does. In the wake of litigation , a state court entered a temporary injunction preventing the state from enforcing the directive while the case is pending. The court found that the governor acted outside his statutory legal authority in issuing the directive, and the plaintiffs will suffer immediate and irreparable injuries, including loss of employment, deprivation of constitutional rights, and loss of medically necessary care. However, the Texas Supreme Court subsequently modified the temporary injunction, finding that the courts lack authority to prevent enforcement of the directive statewide. Instead, the state is prohibited from enforcing the directive only against the plaintiffs involved in the lawsuit while the case is pending. The case is scheduled for trial on July 11, 2022.
• Arizona . In March 2022, Arizona Governor Ducey signed legislation into law that bans physicians from providing gender-affirming surgical treatment to minors. The legislation does not address hormone therapy or puberty blockers.

In addition, since January 2022 15 states introduced a total of 25 bills that would restrict access to gender-affirming care for youth. Provisions in these bills varied considerably and include those that would:

• criminalize or impose/permit professional disciplinary action (e.g. revoking or suspending licensure) on health professionals providing gender-affirming care to minors, in some cases labeling such services as child abuse
• penalize parents aiding in youth accessing gender-affirming care
• permit individuals to file for damages against providers who violate such laws
• limit insurance coverage or payment for gender affirming services or prohibit the use of state funds for such services

Beyond these policies, states have also passed or considered other policies restricting access, including so called “bathroom bills” which restrict access to bathrooms or locker rooms based on sex assigned at birth, the recent Florida “don’t say gay” bill that would prohibit classroom discussion on sexual orientation or gender identity, and laws that limit transgender students’ access to sports. While these policies are not directly tied to health or health care access, their attempts to limit access to social spaces and services and present non-affirming sentiments could negatively impact LGBTQ+ people’s mental health and well-being. For instance, one recent study found that state laws permitting the denial of services to same-sex couples “are associated with increases in mental distress among sexual minority adults.” In addition, and directly related to health care, Florida recently released non-biding guidance recommending against gender affirming care for youth.

What states have introduced protections related to sexual orientation and gender identity in health care?

Though not specific to youth access to gender affirming care, some states have adopted policies that provide health care protections to LGBTQ+ people, including:

• prohibitions on health insurance discrimination based on sexual orientation and/or
• requirements that state Medicaid programs explicitly cover health services related to gender transition

What is federal policy regarding gender-affirming services?

The Biden administration has taken multiple steps to promote access to health care for LGBTQ+ people and to prohibit discrimination on the basis of sexual orientation and gender identity, including:

• On his first day in office, President Biden signed an executive order directing federal agencies to review existing regulations and policies in order to “prevent and combat discrimination” based on gender identity and sexual orientation. The order states that “people should be able to access healthcare…without being subjected to sex discrimination” and views sex nondiscrimination protections as encompassing sexual orientation and gender identity, following the Supreme Court’s Bostock
• On May 10, 2021, also in light of the Bostock ruling, the Biden Administration announced that the Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) would include gender identity and sexual orientation in its interpretation and enforcement of Section 1557’s prohibition against sex discrimination. Section 1557 of the Affordable Care Act (ACA) contains the law’s primary nondiscrimination provisions, including a prohibition on discrimination on the basis of sex by a range of health care entities and programs that receive federal funding. The May 2021 announcement marked both a reversal of Trump Administration policy, which eliminated gender identity and sex stereotyping from the regulations, and an expansion of Obama Administration policy, which included gender identity and sex stereotyping in the definition of sex discrimination but omitted sexual orientation. Following the  Bostock  ruling, two federal district courts issued nationwide preliminary injunctions, blocking implementation of several provisions of the Trump Administration’s regulations related to Section 1557. Biden Administration implementing regulations on Section 1557 are expected to expand on the May announcement.

In addition to establishing a foundation of nondiscrimination policies for LGBTQ+ people, and participating in the Alabama and Arkansas cases as noted above, the administration has responded specifically to the Texas directive, denouncing it as discriminatory and stating that gender affirming care for youth should be supported as follows:

• Statement from President Biden: The statement from the president states that the administration is “putting the state of Texas on notice that their discriminatory actions put children’s lives at risk. These announcements make clear that rather than weaponizing child protective services against loving families, child welfare agencies should instead expand access to gender-affirming care for transgender children.”
• Statement from Dept. of Health and Human Services (HHS) Sec. Becerra : Becerra’s statement reaffirms “HHS’s commitment to supporting and protecting transgender youth and their parents, caretakers and families” and details action items the administration is taking in response to the Texas directive including those that follow below.
• Following the actions in Texas, HHS’s Administration on Children, Youth and Families issued an Information Memorandum to state child welfare agencies writing that child welfare systems should advance safety and support for LGBTQI+ youth, including though access to gender affirming care.
• Specifically, the guidance states that categorically refusing treatment based on gender identity is prohibited discrimination under Section 1557. The guidance also states that Section 1557’s prohibition against sex-based discrimination is likely violated if a provider reports parents seeking medically necessary gender affirming care for their child to state authorities, if the provider or facility is receiving federal funding. The guidance further states that restricting a provider from providing gender affirming care may violate Section 1557.
• The guidance states that in cases where gender dysphoria qualifies as a disability, restrictions that prevent individuals from receiving medically necessary care based on a diagnosis or perception of gender dysphoria may also violate Section 504 and the ADA.
• It also articulates requirements under the Health Insurance Portability and Accountability Act (HIPAA) that prohibit health plans and providers from disclosing protected health information, such as use of gender affirming physical or mental health care without patient consent, except in limited circumstances.

OCR enforces each of these federal laws, and the guidance states that parents or caregivers who believe their child has been denied health care, including gender affirming care, and health care providers who believe they have been unlawfully restricted from providing such care, may file an administrative complaint for OCR to investigate.

What do major medical societies say about gender affirming services?

Most major U.S. medical associations, including those in the fields of pediatrics, endocrinology, psychiatry, and psychology, have issued statements recognizing the medical necessity and appropriateness of gender affirming care for youth, typically noting harmful effects of denying access to these services. These include statements from the American Medical Association , American Academy of Pediatrics , the Endocrine Society , American Psychological Association , American Psychiatric Association , and the World Professional Association for Transgender Health , among others , which in some cases were specifically issued in response to the Arkansas legislation and Texas directive. Further, 23 medical associations or societies, including those named above, together filed an amicus brief in the case filed against Texas Gov. Abbott opposing the state directive. The brief states that denying gender affirming treatment to adolescents who need them would irreparably harm their health and that enforcing the directive would irreparably harm providers who are forced to choose between potentially facing civil and criminal penalties or endangering their patients. A similar amicus brief was filed in the Arkansas case.

Additionally, the Endocrine Society supports gender affirming care for young people in their clinical practice guidelines , as does the World Professional Association for Transgender Health’s standards of care . Together these guidelines form the standard of care for treatment of gender dysphoria.

What are the implications of access restrictions?

State policies restricting youth access to gender affirming care could have significant health and other implications for LGBTQ+ youth, their parents, health care providers, and, in some cases, other community members:

LGBTQ+ youth : LGBTQ+ youth experience higher rates of depression, anxiety, and suicidality than their non-LGBTQ+ peers. In one CDC study of youth in 10 states and 9 urban school districts, a higher share of transgender students reported suicide risk outcomes across a range of metrics than cisgender students. These include, in the past 12 months: having felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Inability to access gender affirming care, such as puberty suppressors and hormone therapy , has been linked to worse mental health outcomes for transgender youth, including with respect to suicidal ideation, potentially exacerbating the already existing disparities. Conversely, access to this care is associated with improved outcomes in these domains. Policies that aim to prohibit or interrupt access to gender affirming care for youth can therefore have negative implications for health in potentially life-threatening ways.

In addition, LGBTQ people report higher rates of negative experiences with medical providers, so creating barriers to gender affirming care could further challenge transgender people’s relationship with the healthcare system.

Finally, with the Texas directive specifically, and in several other states with bills under consideration, youth are vulnerable to secondary trauma, knowing that if they seek such care, their families and providers could be subject to penalties, and, in the case of Texas, children could be separated from their parents.

Parents : In several states with bills under consideration, parents who facilitate access to evidence-based and potentially lifesaving gender affirming services for their children could face penalties. Under the Texas directive, because it is defined as child abuse, parents who facilitate access to gender affirming care for their children, could be subject to penalties, including losing custody of their children. This may place parents in the position of either supporting their children in accessing care supported by medical evidence and facing penalties or denying their children access in an effort not to make their family vulnerable to investigation and potential separation. Each option for parents in this scenario has the potential to be traumatic for the family, and for youth in particular.

Providers: Like parents, providers may be torn between what the medical literature supports is in the best interest of their patients or facing potential sanctions, including violating professional ethics around confidentiality, as in the case of Texas. The American Psychological Association said in a statement that a requirement such as the Texas directive is a violation of both patient confidentiality and professional ethics. Under such circumstances, providers may be forced to decide whether they will provide the highest standard of care for their patients and potentially face sanctions, or obey the state directive but withhold care and potentially violate patient confidentiality and professional ethics. Further, as noted above, the Biden Admiration has stated that HIPAA requirements prohibit providers from disclosing use of gender affirming care without patient consent, except as in narrow circumstances. However, following HIPPA requirements in this case may make providers vulnerable to state sanction under the directive.

Teachers and others : In Texas, in addition to health care providers, other mandated reporters, such as teachers, could also face penalties for failure to report youth known to be accessing gender affirming care. The directive also states that ”there are similar reporting requirements and criminal penalties for members of the general public,” extending the policy’s reach to practically anyone with knowledge of youth accessing these services.

Looking forward

The legal and policy landscape regarding youth access to gender affirming care is shifting across the country, with an increasing number of states seeking to limit such access and impose penalties. Such policies may have significant, negative implications for the health of young people. At the same time, these states are at odds with federal law and policy, and in two recent cases courts have temporarily blocked enforcement of such restrictions. Moving ahead, it will be important to watch how state bills still under consideration unfold and the final outcome of cases in Alabama, Arkansas, and Texas. Decisions in these cases could determine how such policies intersect with existing federal policies — including Section 1557’s prohibition on sex based discrimination in health care, federal disability non-discrimination protections, and HIPAA patient privacy protections — as well as providers’ professional ethics standards.

These states include Alabama, Alaska, Arizona, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Tennessee, Texas, Utah, and West Virginia.

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These states include California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Rhode Island, Vermont, and Washington.

Also of Interest

• LGBT+ People’s Health and Experiences Accessing Care
• The Health System Appears To Be Selling LGBT+ People Short
• The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health

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Medi-Cal Covers Gender-Transition Treatment, but Getting It Isn’t Easy

SANTA CRUZ — From an early age, Pasha Wrangell felt different. Societal expectations of boys, and many characteristics of masculinity, did not match how Wrangell felt inside.

Bullied and ostracized, Wrangell started repressing those feelings in middle school and kept them bottled up for a long time. That led to decades of sadness, isolation, and even a couple of suicide attempts. What gnawed at Wrangell was gender dysphoria, a condition widely acknowledged in the medical community, which causes severe distress to people whose gender identity does not match their sex assigned at birth.

“It’s a sense of wrongness, like someone attached an arm to my head badly, and it just punches me in the face every time,” said Wrangell, 38, who grew up and still lives in this idyllic central California beach community. Facial and body hair is particularly upsetting: “I see my face in the mirror, and anytime I have to deal with hair, it is uncomfortable. I hate seeing it.”

Wrangell is nonbinary, meaning neither a man nor a woman, and uses the pronouns they and them. For over three years, they have been undergoing gender transition treatments to take on more feminine physical traits. These treatments have included genital transformation, known as bottom surgery ; hormone replacement therapy using estradiol; and electrolysis hair removal for their face, neck, and chest.

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All of it is paid for by Medi-Cal, California’s version of the federal Medicaid insurance program for people with low incomes. California law requires Medi-Cal and all other state-regulated health plans to cover gender-affirming care that is deemed medically necessary. But therein lies the rub.

Wrangell, an enrollee of the Central California Alliance for Health, the only Medi-Cal health plan in Santa Cruz, said it has been laborious to get the care they need. They contend with seemingly endless paperwork and phone calls to prove what they’ve already established — that their need for treatments is real and ongoing.

“There is a joke among the trans community, where they are always asking for letters, along the lines of, ‘Oh, did they think I stopped being trans or did the hair magically go away?’” Wrangell said.

And it requires a lot of work to find and vet the scant number of gender-affirming care providers who take Medi-Cal patients, Wrangell said.

Over 1.6 million people ages 13 and older in the U.S. are transgender , according to the UCLA School of Law’s Williams Institute , which conducts legal and policy research on gender identity and sexual orientation. Data from the institute shows an estimated 276,000 transgender people in the U.S. are enrolled in Medicaid, including 164,000 in states where transgender care is covered. Of those, 36,000 are in California, one of 25 states, plus Washington, D.C., whose Medicaid policies cover gender-affirming care.

“I think there’s a lot of pressure in society to fit into a very narrow set of narratives, and I don’t think honestly that works for most people,” Wrangell said. “For some people, it’s so ill-fitting, it’s disastrous.”

A national survey of transgender people shows they disproportionately experience physical abuse, economic hardship, and mental health problems. And research finds gender-affirming care can significantly enhance their quality of life.

But as Wrangell has learned, coverage and care are not the same thing. Hair removal, their top priority, has been hard to get. After 2½ years of electrolysis treatment, they’ve had roughly only about half the total number of hours their electrologist said they needed.

Permanently removing the facial hair of a transgender person assigned male at birth can require 400 or more hours of electrolysis spread over several years. For those paying out of their own pockets, the cost would easily reach tens of thousands of dollars. That doesn’t include the cost of facial, bottom, and body-shaping surgeries.

Wrangell said their health plan has limited the number of sessions it authorizes at a time, requiring constant reauthorization.

Dennis Hsieh, deputy chief medical officer of the Central California Alliance for Health, said the health plan recently updated its policy to allow 50% more electrolysis in a three-month period and eliminate a rule requiring patients to submit photos of relevant body parts.

Hsieh acknowledged a shortage of providers and said the alliance contracts with clinicians across several counties to provide more options.

To a large extent, the challenges transgender people encounter seeking care are the same ones many people face in the “terror dome of U.S. health care,” said Kellan Baker, the executive director of the Washington, D.C.-based Whitman-Walker Institute , which conducts research and education on topics of concern to gay, bisexual, and transgender people. “There are a lot of people in a lot of circumstances who cannot get medically necessary care for their conditions, whether that’s gender dysphoria or cancer or diabetes.”

Legal aid lawyers and transgender activists say another big reason for denials or delays in gender-affirming care, especially hair removal, is that many people in the medical world still think of it as cosmetic.

Medi-Cal, like most commercial insurance plans, does not cover cosmetic treatments. “But if it’s affecting your mental health, and it’s affecting your life opportunities, and it’s affecting your ability to get a job, and it’s affecting your ability to get housing, is that cosmetic?” asked Elana Redfield, the federal policy director at the Williams Institute.

Despite their travails in obtaining care, Wrangell said, the treatment is improving their life. The estradiol, they said, makes them feel “way more relaxed, much less on edge all the time.” And Wrangell feels good about an uncommon bottom surgery they got last October, but they are facing more paperwork for a needed follow-up operation.

They are frustrated about all the red tape they’ve encountered, precisely because the treatments are helping. “This is working,” Wrangell said. “Please finish it.”

This article is part of “ Faces of Medi-Cal ,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

[Update: This article was revised at 5:15 a.m. PT on Aug. 10, 2023, to be more precise with language surrounding gender.]

Related Topics

• Faces of Medi-Cal
• LGBTQ+ Health
• Transgender Health

Copy And Paste To Republish This Story

By Bernard J. Wolfson Updated August 10, 2023 Originally Published August 3, 2023

“It’s a sense of wrongness, like someone attached an arm to my head badly, and it just punches me in the face every time,” said Wrangell, 38, who grew up and still lives in this idyllic central California beach community. Facial and body hair is particularly upsetting: “I see my face in the mirror, and anytime I have to deal with hair, it is uncomfortable. I hate seeing it.”

All of it is paid for by Medi-Cal, California’s version of the federal Medicaid insurance program for people with low incomes. California law requires Medi-Cal and all other state-regulated health plans to cover gender-affirming care that is deemed medically necessary. But therein lies the rub.

Wrangell, an enrollee of the Central California Alliance for Health, the only Medi-Cal health plan in Santa Cruz, said it has been laborious to get the care they need. They contend with seemingly endless paperwork and phone calls to prove what they’ve already established — that their need for treatments is real and ongoing.

“There is a joke among the trans community, where they are always asking for letters, along the lines of, ‘Oh, did they think I stopped being trans or did the hair magically go away?’” Wrangell said.

Over 1.6 million people ages 13 and older in the U.S. are transgender , according to the UCLA School of Law’s Williams Institute , which conducts legal and policy research on gender identity and sexual orientation. Data from the institute shows an estimated 276,000 transgender people in the U.S. are enrolled in Medicaid, including 164,000 in states where transgender care is covered. Of those, 36,000 are in California, one of 25 states, plus Washington, D.C., whose Medicaid policies cover gender-affirming care.

“I think there’s a lot of pressure in society to fit into a very narrow set of narratives, and I don’t think honestly that works for most people,” Wrangell said. “For some people, it’s so ill-fitting, it’s disastrous.”

But as Wrangell has learned, coverage and care are not the same thing. Hair removal, their top priority, has been hard to get. After 2½ years of electrolysis treatment, they’ve had roughly only about half the total number of hours their electrologist said they needed.

Permanently removing the facial hair of a transgender person assigned male at birth can require 400 or more hours of electrolysis spread over several years. For those paying out of their own pockets, the cost would easily reach tens of thousands of dollars. That doesn’t include the cost of facial, bottom, and body-shaping surgeries.

To a large extent, the challenges transgender people encounter seeking care are the same ones many people face in the “terror dome of U.S. health care,” said Kellan Baker, the executive director of the Washington, D.C.-based Whitman-Walker Institute , which conducts research and education on topics of concern to gay, bisexual, and transgender people. “There are a lot of people in a lot of circumstances who cannot get medically necessary care for their conditions, whether that’s gender dysphoria or cancer or diabetes.”

Medi-Cal, like most commercial insurance plans, does not cover cosmetic treatments. “But if it’s affecting your mental health, and it’s affecting your life opportunities, and it’s affecting your ability to get a job, and it’s affecting your ability to get housing, is that cosmetic?” asked Elana Redfield, the federal policy director at the Williams Institute.

Despite their travails in obtaining care, Wrangell said, the treatment is improving their life. The estradiol, they said, makes them feel “way more relaxed, much less on edge all the time.” And Wrangell feels good about an uncommon bottom surgery they got last October, but they are facing more paperwork for a needed follow-up operation.

They are frustrated about all the red tape they’ve encountered, precisely because the treatments are helping. “This is working,” Wrangell said. “Please finish it.”

This article is part of “ Faces of Medi-Cal ,” a California Healthline series exploring the impact of the state’s safety-net health program on enrollees.

We encourage organizations to republish our content, free of charge. Here’s what we ask:

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It’s important to note, not everything on californiahealthline.org is available for republishing. If a story is labeled “All Rights Reserved,” we cannot grant permission to republish that item.

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Fact check: Post distorts California bill about mental health services for children

The claim: California bill could strip custody from parents who refuse gender-affirming surgery

An April 10 Instagram post ( direct link , archived link)  shows an image of what appears to be the text of a bill.

“CA bill seeks to remove custody from parents and provide 'gender affirming' therapy to children without parental consent," reads text featured below the image of the bill.

Part of the post’s caption reads, “If the bill becomes law; children who wish to seek ‘gender affirming’ surgery who have parents that will not permit such mutilations, will be able to be removed from the custody of their parents.”

The post generated over 900 likes in less than a week. 

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Our rating: False

The California bill referenced in the bill would not change parental custody laws, according to the bill sponsor and legal experts. It also won’t change requirements for parental consent, which is currently required for gender-affirming surgery. Rather, it seeks to expand on existing laws concerning the consent of minors receiving mental health treatment and residential services.

Bill doesn't change existing parental custody laws

California lawmakers introduced Assembly Bill 665 , which seeks to allow some children between the age of 12 and 17 to receive mental health treatment without parental consent or notification, in February.

But there is nothing in the bill that allows children to be removed from their parent's custody, according to the bill's sponsor and legal experts.

"This bill makes no changes to the processes of the child welfare system in California and no changes to the processes of removal from a home," California Democratic State Rep. Wendy Carrillo , the bill's sponsor, said in an email to USA TODAY.

Joshua Jones, a legal writing professor at California Western School of Law, agreed that nothing about the proposed bill adds anything to existing child welfare laws that would allow a child to be taken from their parents.

Under California law, the removal of children from their parents' custody typically occurs when there are concerns about the child's safety and well-being, or when there is evidence of abuse, neglect or abandonment, Simona Grossi, a law professor at Loyola Law School, told USA TODAY.

Fact check: False claim cows, pigs will start getting mRNA vaccine in April 2023

“The court must find clear and convincing evidence that there is a substantial danger to the child's physical health, safety, protection, or physical or emotional well-being, and that there are no reasonable means to protect the child without removal,” Grossi said in an email. " Cal. Welf. & Inst. Code § 366.26 provides for the procedures for conducting hearings to terminate parental rights or determine adoption, guardianship, or placement of children adjudged dependent children of juvenile court."

Scott Altman , a law professor at the University of Southern California, said that the bill does permit temporary stay in a residential shelter. But that is not the same as taking custody away from parents, which requires a showing of danger to the child, he said.

Bill doesn't allow for gender-affirming surgery without parental consent

Altman said the proposed bill allows the state to bypass parental consent for some mental health care, which might be gender-affirming, but it wouldn't allow gender-affirming surgery without consent. 

Assembly Bill   665  expands on existing laws around consent for minors regarding outpatient mental health or counseling services and shelter services, experts say. It would correct an inequity that separates the type of care available by the type of insurance used.

The bill, if passed, would allow minors between the ages of 12 and 17 to be treated by mental health professionals in outpatient services or residential shelter services without parental consent or notification if the child is deemed "mature enough to participate intelligently" and if parental involvement is determined to be "inappropriate."

The existing law, signed in 2010 by former California Gov. Arnold Schwarzenegger, allows minors ages 12 to 17  on private health insurance to consent to mental health and residential shelter services. But the law doesn't apply to recipients of  Medi-Cal, a state Medicaid program that pays for the medical services of low-income families. 

The proposed bill would ensure that Medi-Cal-insured youth have the same access to those services without the need for parental consent, according to Carrillo.

Fact check:  No, new Canadian bill won't allow prosecution of those who misgender others

USA TODAY reached out to the social media user who shared the claim for comment.

The Associated Press also debunked this claim.

Our fact-check sources:

• Scott Altman, April 17, Email exchange with USA TODAY
• Mary Persyn , April 17, Email exchange with USA TODAY
• Joshua Jones , April 17, Email exchange with USA TODAY
• Simona Grossi, April 17, Email exchange with USA TODAY
• Wendy Carrillo, April 18, Email exchange with USA TODAY
• California Legislative Information, accessed April 18,  Senate Bill No. 543
• California Legislative Information, accessed April 18, Assembly Bill 665
• California Legislative Information, accessed April 18,  WELFARE AND INSTITUTIONS CODE - WIC
• National Association of Social Workers, accessed April 19,  SENATE BILL SB 543

Thank you for supporting our journalism. You can subscribe to our print edition, ad-free app or electronic newspaper replica here .

Our fact-check work is supported in part by a grant from Facebook.

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Newsom Signs Bill Making California ‘Sanctuary’ for Child Gender Transition

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On Thursday, California governor Gavin Newsom signed legislation that would facilitate child gender-transition tourism from other states.

The bill, spearheaded by Democratic state senator Scott Wiener, aims to make California a “sanctuary state” for out-of-state children to receive so-called gender-affirming surgery and hormone therapy without the knowledge or consent of their parents. The bill includes a number of provisions designed to insulate residents of red states that have banned child gender-transition from prosecution.

It prohibits California courts and lawyers from enforcing subpoenas imposed by other states demanding that healthcare providers disclose when they perform such medical procedures on minors.

Wiener has been behind multiple lawmaking efforts in the state to undermine parental rights. In January, he pitched a bill that would allow minors to be vaccinated without parental permission .

Under the gender-transition law, California courts will have “temporary emergency jurisdiction” over any child and the person who accompanied the child to California to obtain the invasive medical interventions.

California’s law enforcement vows to treat any potential out-of-state arrest warrant issued for violating laws against child gender transitioning with “the lowest law enforcement priority,” according to the bill.

“California law enforcement agencies shall not knowingly make or participate in the arrest or participate in any extradition of an individual pursuant to an out-of-state arrest warrant for violation of another state’s law against providing, receiving, or allowing a child to receive gender-affirming health care and gender-affirming mental health care in this state, if that care is lawful under the laws of this state, to the fullest extent permitted by federal law,” the law reads.

In his signing message, Newsom claimed the legislation would empower parents by giving them “choice” rather than effectively strip custody from them, as many Republicans have alleged.

“In California we believe in equality and acceptance. We believe that no one should be prosecuted or persecuted for getting the care they need — including gender-affirming care,” Newsom said. “Parents know what’s best for their kids, and they should be able to make decisions around the health of their children without fear. We must take a stand for parental choice.” He also claimed that Republican-controlled states that have limited or outlawed sex-change surgeries for children in order “demonize” people who identify as LGBT.

A severability clause, which would allow the remainder of the bill to apply even if some provisions are held to be illegal or otherwise unenforceable, was included in an amendment at the last minute, according to the Los Angeles Times ,  because of doubts about the bill’s constitutionality.

Wiener admitted to the publication that proponents of the bill aimed to push the bounds of what is permissible under the Constitution, adding that California should not serve as “an arm of law enforcement of the states of Texas or Alabama.”

“We may have limits under the U.S. Constitution, but we are going to go right up to the edge of what we’re able to do to protect them and say, ‘Unless we are absolutely forced to send you back, we are not going to send you back,’” he said of child arrivals to California, and their guardians, seeking transition ‘treatment.’

More from National Review

Newsom Blasts Book Banning in K-12: ‘Education Is under Assault’

California School Board May Open Planned Parenthood Clinic at LA High School

Moms for Liberty Locked Out of Twitter after Criticizing California Gender-Transition Bill

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Perspective: A reckoning is coming for California

California voters and policymakers aren’t on the same page on gender ideology.

By Valerie Hudson

California has always been in the forefront of issues concerning all things transgender. The 2019 Gender Recognition Act allows for change of gender by request on all government documentation, such as birth certificates and driver’s licenses. SB107 offers sanctuary to transgender youth fleeing states where transgender-related care, such as puberty blockers, cross-sex-hormones and sex reassignment surgery, are illegal for minors. 

Under California law , shelters are to admit individuals on the basis of gender identity and not sex, and ditto for any other facilities, such as gyms or spas or restrooms, that are single-sex: single-sex means single-gender in California. Furthermore, no documentation of gender identity, such as a driver’s license, is necessary; only an assertion of gender is required.

In California, employer-provided health plans must cover transgender-related care. Still another law allows prisoners to be housed according to gender identity, not sex. There are many other trans-related laws that could be mentioned that California has passed — more than any other state — making the state stand out in this area.

And some municipalities in California have even gone further. San Francisco offers a $1,200 per month guaranteed income to trans individuals for 18 months. The city also provides housing subsidies for them as well. Other cities such as Palm Spring and San Diego have similar initiatives underway.

All of this legislative and policy activity seems to suggest that the majority of Californians are in agreement with the direction their state government is taking on these issues. A new poll, however, seems to suggest that may not actually be the case. A November 2023 poll conducted by Spry Strategies of 1,000 likely California voters, with a margin of error of 3.1%, contains quite a few surprises. 

The sample was stratified to match overall demographic and party affiliation among California voters. So, for example, about 47% of California voters are Democrats , and the sample has 48% Democrats. About 52% of California voters are white, and that percentage was matched in the sample. Age, sex and other characteristics were also matched.

The first question of note was whether the respondent thought sex was binary — that is, male and female only.  Sixty-two percent responded in the affirmative, while only 22% did not believe sex was binary. More than 70% stated that the definition of a woman was someone who was “biologically born female.” And 72% of respondents stated that parents should be notified if their child identified as transgender in school. These are strong majorities.

Turning to single-sex activities, 59% stated that males who identify as females should not compete in women’s sports, with only 28% saying they should be allowed. Sixty-four percent stated males who identify as females should not be allowed in areas where women are changing or showering, with only 26% saying they should be allowed. Sixty percent stated that males who identify as females should not be housed in women’s prisons (rising to 68% when the perpetrator was convicted of domestic abuse or sexual assault), with 25% stating they should (declining to 16% in case of domestic abuse/sexual assault).

With regard to domestic violence shelters, 61% felt that males who identify as females should not be allowed, with 24% saying they should.  Sixty-three percent opposed all gender-affirming care (puberty blockers, cross-sex hormones, surgery) for minors, with 21% saying it should be allowed. Sixty-eight percent thought parents should not lose custody if they fail to affirm their child’s gender (as has been threatened by the state legislature), with only 12% favoring such a course of action.

Across all these survey questions, at least 2-3 times as many California voters rejected demands that biological sex be erased as a matter of law and policy, compared to the number that supported erasure. This is a robust rejection across the board, and a truly stunning result.

Furthermore, a similar survey was conducted among Californian voters three years ago with a slightly smaller sample size, with a margin of error of up to 4%. A comparison of the results shows that the percentage of California voters rejecting the erasure of biological sex has risen significantly in that short time span. Rather than becoming more acceptant, the Californian electorate has become more cautious over time.

For example, in the 2020 survey, 54% of respondents did not want males who identify as female in female changing rooms and showers; in 2023, that had increased to 64%, a jump of 10 percentage points. With regard to prison placement, in 2020 the percentage objecting was 46%; in 2023, it was 60%, a jump of 14 percentage points. For domestic violence shelters, 46% objected; in 2023 it was 61%, a jump of 15 percentage points.

That magnitude of jump, in the space of three years, is stunning. The longer Californians think about it and the more experience they have with the consequences, the less they are on board with the direction their state government is taking.

And despite its reputation as an outlier, on these issues, the Californian electorate is not out of step with the national electorate. A national Pew survey in 2022 found similar percentages opposed to the erasure of biological sex in sports (58% opposed), and asserting that sex is binary (60%), all very much in line with the thinking of Californians today. This survey too found evidence that the rejection of sex erasure was increasing over time, not decreasing.

A reckoning is coming. Whether you call this a democratic reckoning or a reckoning with common sense, candidates should beware. The political pendulum is swinging back more swiftly and with a greater degree of consensus behind it than anyone could have possibly imagined — even in California.

Valerie M. Hudson is a university distinguished professor at the Bush School of Government and Public Service at Texas A&M University and a Deseret News contributor. Her views are her own.

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Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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TLDEF's Trans Health Project

Gender reassignment surgery.

Policy: Gender Reassignment Surgery Policy Number: BSC7.02 Last Update: 2021-04-01 Issued in: California

Body Contouring:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section): Calf implants Gluteal and hip augmentation (implants/lipofilling) Liposuction (removal of fat in the hips, thighs, or buttocks) Pectoral implants Suction-assisted lipoplasty of the waist

Breast Reconstruction:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section): Breast enlargement procedures, including augmentation mammoplasty, implants, and silicone injections of the breast

Facial Reconstruction:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section): Blepharoplasty/Brow reduction/brow lift (removal of redundant skin of the upper and/or lower eyelids and protruding periorbital fat) Chin augmentation (reshaping or enhancing the size of the chin) Chin/nose/cheek implants Face lift/forehead lift (e.g., rhytidectomy) Facial reconstruction for femininization or masculinization (e.g., facial bone reduction) Forehead augmentation Hair reconstruction (hair removal/hair transplantation) Jaw/mandibular reduction or augmentation Lipofilling Lip reduction/enhancement (decreasing/enlarging lip size) Rhinoplasty (reshaping of the nose) including nose implants Trachea shave (Adam’s apple shaving)/reduction thyroid chondroplasty (reduction of the thyroid cartilage)

Permanent Hair Removal:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section): Electrolysis or laser hair removal for facial, or body areas other than pubic region. Reevaluation by a qualified medical provider is needed if treatment exceeds 6 months or 30 hours. Pubic area electrolysis or laser hair removal may be considered medically necessary when there is a recommendation from the surgeon (with documentation in the medical record) of the need to be done related to a planned genital reconstructive surgery. This treatment can be done during the same time period as hormonal therapy and living in the preferred gender role full time. Photographic and endocrinologist documentation is not required. Re-evaluation by a qualified medical provider is needed if treatment exceeds 6 months or 30 hours.

Voice Therapy and Surgery:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section): Cricothyroid approximation (voice modification that raises the vocal pitch by stimulating contractions of the cricothyroid muscles with sutures) Laryngoplasty (reshaping of laryngeal framework) Voice modification surgery and voice retraining (speech therapy)

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Updated on Nov 23, 2021

Wyoming governor signs bill banning gender reassignment surgery, care

March 23 (UPI) -- Wyoming's Republican governor has signed a bill into law banning doctors in that state from performing gender transitioning and gender reassignment procedures for children.

Wyoming became the 24th state to enact similar legislation after Gov. Mark Gordon signed the bill Friday.

Legislators in both the state House and Senate passed the legislation earlier this month.

"I signed SF99 because I support the protections this bill includes for children, however it is my belief that the government is straying into the personal affairs of families," Gordon said in a statement.

"Our legislature needs to sort out its intentions with regard to parental rights. While it inserts governmental prerogative in some places, it affirms parental rights in others," he said.

In addition to doctors, the law also subjects pharmacists and other healthcare professionals to legal penalties for providing gender-affirming care to minors, including the revocation of licenses.

"There was an opportunity to find common cause on issues we agreed with: surgery for minors is inappropriate, other healthcare options ... should remain the purview of parents and their qualified physicians," Wyoming Equality Executive Director Sara Burlingame said in a statement to WyoFile .

She said she was "dismayed" at the new law, calling it a clear case of "government overreach."

Two states, Montana and Idaho have had similar bans blocked by federal judges.

Last month, officials in Idaho asked the Supreme Court to allow the state to enforce its felony ban on minors receiving gender-affirming healthcare, calling the scope of the lower court's decision too broad.

Rates of Suicide Attempts Doubled After Gender-Reassignment Surgery

Attempted suicide rates among people who identified as transgender more than doubled after receiving a vaginoplasty, according to a peer-reviewed study published in The Journal of Urology.

Researchers found the rates of psychiatric emergencies were high both before and after gender-altering surgery, with similar overall rates in both groups. However, suicide attempts were markedly higher in those who received vaginoplasties.

“In fact, our observed rate of suicide attempts in the phalloplasty group is actually similar to the general population, while the vaginoplasty group’s rate is more than double that of the general population,” the study authors wrote.

Among the 869 patients who underwent vaginoplasty, 38 patients attempted suicide—with nine attempts before surgery, 25 after surgery, and four attempts before and after surgery. Researchers found a 1.5 percent overall risk of suicide before vaginoplasty and a 3.3 percent risk of suicide after the procedure. Almost 3 percent of those who attempted suicide after undergoing vaginoplasty did not present with a risk of suicide prior to surgery.

Among the 357 biologically female patients who underwent phalloplasty, there were six suicide attempts with a 0.8 percent risk of suicide before and after surgery.

Overall, the proportion of those who experienced an emergency room and inpatient psychiatric encounter outside of suicide attempts was similar between the vaginoplasty and phalloplasty groups. Approximately 22.2 percent and 20.7 percent of patients, respectively, experienced at least one psychiatric encounter.

Suicide Rate 19-Fold Higher

“It’s hard to refute this paper because it’s a longitudinal study,” Dr. Oliva said. “In Sweden, everyone is in a database, and through diagnosis codes, they’re able to follow what happens to every citizen in terms of their medical history. They waited more than 10 years after people had surgery and found that death by suicide had an adjusted hazard ratio of 19.1.”

Surgical Procedures

A penial inversion is the most commonly performed procedure where the skin is removed from the penis and inverted to form a pouch that is inserted into the vaginal cavity created between the urethra and the rectum. Surgeons then partially remove, shorten, and reposition the urethra and create a labia majora, labia minora, and clitoris.

Another surgical method involves using a robotic system that enables surgeons to reach into the body through a small incision in the belly button to create a vaginal canal. The type of vaginoplasty performed varies among patients. For example, younger patients who have never experienced puberty may have insufficient penile skin to do a standard penile inversion.

Vaginoplasty Associated With Serious Risks

“For cosmetic surgery, if the complication rate was more than 2 percent to 3 percent, you wouldn’t have any patients,” Dr. Oliva told The Epoch Times. “These are very high percentage rates that we just accept.”

Dr. Oliva said complications with these surgical procedures are very high and he thinks this is why suicide rates are so high.

“People think this is going to solve the problem and it doesn’t,” he said.

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