LGBTQ POLICY SPOTLIGHT:BANS ON MEDICAL CAREFOR TRANSGENDER PEOPLE

State currently bans or restricts best practice medical care for at least some transgender people (19 states)

State has considered a billto ban or restrict best practice medical care for at least some transgender people (since 2017) (20 states)

State has no bill or law banning best practice medical care for transgender people (11 states + D.C.)

Note: This map shows legislative efforts to ban or restrict medical care for transgender people since 2017 (light red).This map also shows any curent ban or restriction,including those that pre-date 2017,on medicall necessary care for transgender people,whether through youth-specific bans,private insurance,or state Medicaid programs (dark red). Source: MAP's Equality Mapsandbilltracking.Data as of April15,2023.

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This report was authored by:

Movement Advancement Project

MAP's mission is to provide independent and rigorous research, insight,and communications that help speed equality and opportunity for all people.MAP works to ensure that all people have a fair chance to pursue health and happiness,earn a living, take care of the ones they love,be safe in their communities,and participate in civic life.For more information, visit www.mapresearch.org.

Contact Information

Movement Advancement Project
190515th Street #1097
Boulder, CO 80306
1-844-MAP-8800
www.mapresearch.org

MAP is very grateful to the following major funders, whose generous support makes it possible for us to do our work:

David Bohnett Foundation

David Dechman & Michel Mercure

Gill Foundation

Esmond Harmsworth

Evelyn & Walter Haas, Jr. Fund

Jim Hormel

Johnson Family Foundation

Laughing Gull Foundation

Weston Milliken

Ineke Mushovic

The Palette Fund

Mona Pittenger

Ronald W. Naito MD Foundation

MacKenzie Scott

Ted Snowdon Foundation

Tzedek Social Justice Fund

Van Ameringen Foundation

Wild Geese Foundation

Acknowledgments

Corinne Green, Equality Federation

Michelle M.Johns, NORC at the UniversityofChicago

Sara Mar, Whitman-Walker Institute

Vivian Topping, Equality Federation

The Williams Institute, UCLA

EXECUTIVESUMMARY..
INTRODUCTION..
THEIR GOAL: ERADICATE TRANSGENDER PEOPLE.
CURRENT POLICY LANDSCAPE: TRANSGENDER PEOPLE'S ACCESS TO MEDICAL CARE.....2
RECENT EXPLOSION OF BILLS THAT WOULD BAN MEDICALLY NECESSARY CARE
FOR TRANSGENDER PEOPLE...
OVER TIME, TRANSGENDER HEALTHCARE BANS ARE GROWING IN SCOPE AND EXTREMISM...10
Growing Application to Transgender Adults. ..10
Growing Bans on State-Funded Health Care.. ..2
Restrictions or Waivers for Private Insurers. ..12
Shifting Punishments, Including Growing Power for States'Attorneys General. ..3
Expanding Targets From Doctors to Parents,Teachers,and More. ...4
Defining Sex,With Potentially Far-Reaching Implications.. ...4
Allowing Non-Consensual Surgeries on Intersex Children... ..5
Forced Outing of Transgender Children.. ….6
Other Provisions... .7
THE IMPACTS OF EFFORTS TO BAN MEDICAL CARE FOR TRANSGENDER PEOPLE.
Harm to Transgender People & Their Families . ..9
Harm to Medical Providers &The Broader Community. ..00
CONCLUSION... ...22
ENDNOTES... ..23

Duetothenaturefonggateesiveseiossomeofhumbrsitediniseprtwilli change.Inthis report,billanalysis data reflectbilsintroduced through April1,2023;laws on thebooksare current asof April15,2023.The various LGBTQ EqualityMaps referenced in the report,and others,willcontinue to beupdated inreal time aspolicieschange.Thosemapsareavailableatmapresearchorg.

EXECUTIVESUMMARY

In less than three months, 2023 has already set new records for anti-LGBTQ,and especially anti-transgender, legislation in the United States. In particular, 2023 has brought devastating and unprecedented attacks on transgender people and their ability to live safely and freely.This is nowhere more evident than in the escalating efforts to restrict, ban,and even criminalize transgender people's access to medically necessary care， sometimes also called "gender-affirming care!"

While most of the public focus has been on recent efforts to ban medical care for transgender youth, this report shows how these attacks are part of a much larger effort to ban medical care for all transgender people. In fact, just days before this report's publication,Missouri became the first state to efectively ban gender-affirming care for all transgender people, regardless of age.

The findings demonstrate how recent bills to ban or restrict medical care for transgender people are growing in number, growing in scope, and growing more and more extreme to harm more people than ever before. This shows that the ultimate goals of these bills,and of the extremists and politicians pushing them,are to make it impossible for transgender people to transition, to be their authentic selves,and even to exist.

Current Policy Landscape: Transgender People's Access to Medical Care

Historically， it has been notoriously difficult for transgender people to access gender-affirming care. Transgender people face extraordinarily high rates of employment discrimination，blocking their access to health insurance and economic security. Even those with health insurance have faced decades of obstacles such as discrimination in healthcare settings，a scarcity of competent,affrming medical providers,and insurance companies routinely denying coverage of such care, despite its medical necessity. Both legislation and administrative policies have also blocked access to or denied coverage of transgender-related health care, such as in state Medicaid policies and more.

Today,it remains diffcult for many transgender people to access best practice medicine.For example:

Only 22 states，Puerto Rico,and the District of Columbia currently ban discrimination in health insurance on the basis of gender identity, meaning that such discrimination is legal under state law in over half of U.S. states.

· Only 24 states and the District of Columbia ban "transgender exclusions” in insurance, meaning that, in the other 26 states, state law allows health insurance companies to categorically refuse to cover any transgender-related health care.

· At least 11 states explicitly exclude coverage of medically necessary care for transgender people in the state Medicaid program, including two states whose exclusions apply to minors only—though in practice these exclusions will likely set precedent for future,broader exclusions.Thirteen states have no explicit policy,and this absence of a clearly inclusive policy leads to obstacles and inconsistent access to health care for transgender people.

Currently, 15 states ban best practice medical care for transgender youth, including one state that bans only surgical care for transgender youth. Prior to 2021, no state had a ban on medically necessary care for transgender youth. As a result, today, nearly one in five (19%) transgender youth live in states that ban medically necessary care for transgender youth,and that number is certain to grow in the coming months as many more states are still actively pursuing similar bans.

Importantly， these discriminatory and exclusive policies are especially harmful to transgender people of color, and particularly Black transgender people, who are more likely to live in states with such laws.

Recent Explosion of Bills That Would Ban Medically Necessary Care for Transgender People

For this report, MAP identified more than 250 bills attacking health care for transgender people, covering 2017 to April 1,2023.This analysis reveals:

· Very few such bils were introduced from 2017 to 2019, illustrating that this is a recently manufactured "problem"designed for political purposes.

· The current wave of legislation attacking transgender health care began in 2020,when over a third of states (17) considered such a bill.

· In just the first three months of 2023,more bills attacking transgender health care have been introduced than in the last six years combined. Virtually all these bills explicitly target transgender youth, though, as shown in this report, a growing share of these bills would also restrict access to health care for at least some transgender adults.

· From 2017 to April 2023,more than three-quarters of states (39） have considered a bill attacking transgender health care,including 15 states that have enacted new bans or restrictions.

Over Time, Transgender Healthcare Bans Are Growing in Scope and Extremism

MAP analyzed the more than 250 bills introduced between 2017 and April 1,2023,with a particular focus on the bills introduced since 2020 when the current wave of anti-transgender legislation began.While all of these bills seek to ban or restrict medical care for at least some transgender people, MAP also analyzed the many other provisions often also contained within these bills,as well as trends over time.The findings show the dramatic and escalating attacks on transgender people, including:

Banning care for transgender adults.In 2020,only one bill applied to at least some transgender adults, but in 2023, nearly three in 10 (29%) bills would ban or restrict care for at least some transgender adults (in addition to youth). This growing extremism is now a stark reality in Missouri, which in April 2023 became the first state to effectively ban care for all transgender people.

Banning state funds for medical care.In 2020, no bills contained such a provision, but nearly half of the 2023 bils would ban state funds from going toward best practice medical care for at least some transgender people.

Banning private insurance coverage or allowing refusals of coverage.Some bills also prohibit private insurers from covering or reimbursing medically necessary care for transgender people,while other provisions allow insurers to categorically refuse to cover such care.

Criminal charges and other penalties. Bills vary in their penalties, ranging from a loss of medical license for a healthcare provider to lawsuits, criminal and/ or child abuse charges, as well as a growing trend of empowering state Attorneys General to take further action to end gender-affrming care.

：Expanding targets.While most bills target medical providers,more than a third of all bills from 2020 through 2023 target someone other than or in addition to medical providers—such as parents of transgender children,teachers,or even friends or neighbors.

·Forced outing of transgender youth. In addition to banning health care,at least 16% of all bills from 2020 to 2023 contain explicit provisions that would force school staff, and sometimes any government employee,to out youth to their parent(s) if they express any thought or indication they may be transgender—often regardless of whether the home environment might be safe for that student.

Exceptions for intersex children. Across all bills from 2020 to 2023,at least 81% of bils attacking transgender health care also contain explicit exceptions allowing non-consensual surgeries on intersex children.

Exclusionary definitions of sex.Across all bills from 2020 to 2023，more than two-thirds (69%) of bills would also create new, explicit legal definitions of sex that would effectively erase any legal recognition of transgender people, with the potential to restrict their rights throughout state law, not only in health care.

· And more. Each year， new provisions emerge, illustrating the continuing efforts to both ban care for transgender people and to use these bills as a vehicle for other anti-transgender attacks.

The lmpacts of Efforts to Ban Medical Care for Transgender People

Bills trying to restrict or outright ban medically necessary care for transgender people all try to take decisions away from patients, their families,and their doctors,and instead give that power to politicians and bureaucrats. People who don't have a transgender child may not understand the nuances of this medical care, it is parents, doctors,and the patient who should decidenot politicians. Unsurprisingly， banning such medical care entirely causes clear and direct harm to transgender people,as well as their families,medical providers,and broader communities.

Conclusion

Across the country,anti-transgender extremist groups and politicians are putting the lives and well-being of transgender people at risk by outlawing access to best practice medical care-despite this care being backed by decades of research and supported by the American Medical Association, the American Academy of Pediatrics, and every leading health authority.While these bills are startling and dangerous on their own, they must also be recognized for what they are: part of a broader effort to prevent transgender people from existing at all.

INTRODUCTION

There is an all-out war against LGBTQ people,and particularly transgender people, in the United States.a While 2022 was a record year for anti-LGBTQ bills introduced and passed into law,only six weeks into 2023 that record was broken: in all of 2022, there were 315 anti-LGBTQ bills introduced in state legislatures, but by mid-February 2023,there were over 400 such bills,and last year's record number of newly enacted anti-LGBTQ laws had also been broken.' By April 1,2023,there were over 650 such bills.2

There are many different fronts to this battle,ranging from efforts to rollback LGBTQ-inclusive laws (where they exist) to bans on transgender students playing sports, a reemergence of bathroom bans and "Don't Say Gay and Trans" laws, restrictions on drag performances,and much more.This report focuses on recent and escalating efforts to restrict,ban,and even criminalize transgender people's access to medically necessary health care, sometimes also called "gender-affirming care."

While most of the public focus has been on recent efforts to ban medical care for transgender youth, this report shows how these attacks are part of a much larger effort to ban medical care for all transgender people一 with the ultimate goals of making it impossible for transgender people to transition,to be their authentic selves,and even to exist. The findings illustrate how these attacks on transgender health care are growing in number, growing in scope,and growing more extreme to harm more people than ever before.In fact, just days before this report's publication,Missouri became the frst state to effectively ban care for all transgender people.

Across the country， anti-transgender extremist groups and politicians are putting the lives and wellbeing of transgender people at risk by outlawing best practice medical care-despite this care being backed by decades of research and supported by the American Medical Association， the American Academyof Pediatrics,and every leading health authority.These bills are startling and dangerous in that they allow politicians to interfere in medical decisions that should be left to patients, their families,and their healthcare providers, in accordance with best practice medical standards. While these bills are dangerous enough on their own, they must also be recognized for what they are: part of a broader effort to prevent transgender people from existing at all.

THEIR GOAL:ERADICATETRANSGENDERPEOPLE

From efforts to ban transgender-related health care or the ability of transgender people to obtain accurate identity documents, to restricting transgender people's ability to use the restroom or to play sports with their peers,anti-LGBTQ activists and politicians have become more explicit and brazen in their ultimate objective: erasing transgender people from society.

Whilemanyanti-transgenderpoliciesand proponents frame their goal as "protecting children" over recent years,and especially in 2023, their true goal has become clearer and more explicitly stated. Their goal, simply put,is to prevent transgender people from existing.High profile individuals and extremists have called transgender people "demonic"3 and mentally ill,4 and coordinated anti-transgender campaigns regularly and openly fear-monger about the supposed dangers of "radical gender ideology"5 and that transgender people are “coming for your kids." At a 2023 conservative political conference, one speaker stated plainly,"Transgenderism [sic] must be eradicated from public life entirely."7

The hysteria and relentless attacks that opponents are encouraging are also clearly politically motivated and extremely coordinated.In an interview with The New York Times,a far-right political leader and organizer of these and other anti-transgender efforts said explicitly that their efforts to ban transgender children's access to medicine was, simply,a "winning issue." In a review of leaked emails,a March 2023 investigation found that coordinated efforts to ban health care for transgender youth have been underway since at least 2019 among anti-transgender activists,doctors,lawyers,and far-right organizations—with broader coordination on pushing anti-transgender attacks for nearly a decade.9

aSee MAP'songoing series Under Fire(2O23) for more detail on the wide-ranging attacks on LGBTQ people across virtually every aspectoflife.

MotherJones

Inside the Secret Working Group That Helped Push Anti-Trans Laws Across the Country (click to read more)

CURRENT POLICYLANDSCAPE:TRANSGENDERPEOPLE'S ACCESSTO MEDICAL CARE

Historically,it has been notoriously difficult for transgender people to access gender-afirming care. Transgender people face extraordinarily high rates of employment discrimination，blocking their access to health insurance and economic security.1° Even those with health insurance have faced decades of obstacles such as discrimination in healthcare settings,a scarcity of competent,afirming medical providers,and insurance companies routinely denying coverage of such care, despite its medical necessity.11 Both legislation and administrative policies have also blocked access to or denied coverage of transgender-related health care, such as in state Medicaid policies,as discussed next.

Today,it remains difficult for many transgender people to access best practice medicine, though over time there has been relative improvement一at least in some states. Importantly, these obstacles to medical care disproportionately impact transgender people of color,as shown in the"By the Numbers"spotlight on this page and discussed further on pages 5 and 14.

For example,and as shown in Figure 1 on the next page，only 22 states,Puerto Rico,and the District of Columbia currently ban discrimination in health insurance on the basis of gender identity.Additionally, only 24 states and the District of Columbia ban"transgender exclusions" meaning that health insurers in those states are no longer allowed to categorically refuse to cover transgenderrelated health care.As recently as 2012，no states prohibited transgender exclusions in insurance.1² Despite this progress,more than half of states still lack health insurance nondiscrimination protections for transgender people,or effectively permit insurers to refuse to cover medically necessary care for transgender people.

Similarly, transgender people face ongoing obstacles to medically necessary care in state Medicaid programs. Medicaid coverage is especially important as Medicaid provides health insurance to low-income individuals, among other vulnerable groups,and transgender people are much more likely to have low incomes. For example, more than one in five transgender people (21%) live in poverty, nearly twice the rate of straight cisgender adults (12%).1³ These higher rates of poverty are due at least in part to widespread discrimination in employment, housing,and public places, preventing many transgender people from building economic security.

By the Numbers: Transgender People's Obstacles to Health Care

In a 2015 national survey of over 27,000 transgender and nonbinary adults:

· 14% of transgenderpeople(including 20% of Black transgender people) lacked health insurance, higher than the nationwide rate of 11% that year.

· 25% of transgender people reported a problem with their insurance in the past year related to being transgender, such as being denied coverage for transgender-related care.

· 33% of transgender people (with even higher rates for transgender people of color and transgender people with disabilities) said they couldn't see a doctor when they needed to in the past year due to the cost.

· 33% who had seen a healthcare provider in the past year had at least one negative experience, such as being refused treatment or being verbally harassed.

Source:Jamesetal.2016.TheReportofthe015U.S.ansgenderSurveyWashgton DC:NationalCenterforTransgenderEquality

Figure 2 on the following page shows that currently, only roughly half of states explicitly include transgenderrelated health care in their Medicaid program.At least 11states explicitly exclude coverage of medically necessary care for transgender people, including two states whose exclusions apply to minors only—though in practice these exclusions will likely set precedent for future, broader exclusions.Thirteen states have no explicit policy either way; while this should mean that gender-affirming care is covered in these states (because it is medically necessary), in practice the absence of an explicit， inclusive policy often leads to transgender people experiencing denials of coverage and other obstacles to care.

As these maps illustrate,access to best practice medical carefortransgenderpeopleremains complicated and varies from one state to the next. Past efforts to block this care have largely been limited to relatively specific domains,such as in Medicaid or by allowing insurers to refuse to cover such care (but not banning such care entirely).

Source: MAP's Equality Maps.Data as of April 15,2023.

Source:MAP's EqualityMaps.Dataas of April15,2023.

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But now, in just the last few years,a new area of policy has quickly emerged and rapidly evolved, targeting transgender youth's—and increasingly, all transgender people's-access to medically necessary care and attempting to explicitly ban such care entirely, under any circumstances.

Prior to 2021, no state had a law specifically banning medical care for transgender youth. Yet, in just two short years,and as shown in Figure 3,15 states now ban or restrict medical care for transgender youth,with 12 of those bans becoming law in 2023 alone—and with Missouri becoming the first state to effectively ban (or at minimum,severely restrict) care for all transgender people,regardless of age. As a result,nearly one in five (19%) transgender youth,as well as all transgender adults in Missouri, now live in states where they are banned from receiving medically necessary care.14

Additionally，multiple states without bans have attempted to restrict this care through other means, as shown in Figure 3—and typically after attempted legislative bans fail. In Texas,for example, the state

Nearly 1 in 5 (19%)

transgender youth now live in states where
they are banned from receiving medically necessary care (As of April 15,2023)

legislature failed to pass a ban in 2021,and so in 2022, the state's attorney general and governor announced that best practice medical care for transgender children amounted to criminal child abuse and directed the state's Department of Family Protective Services to enforce their opinion. These efforts did not change state law,and courts later ruled these actions beyond the power of the governor.15 However， the efforts nonetheless resulted in numerous investigations into families with transgender children,and in the 2023 legislative session,Texas is considering over 20 different bills to ban or restrict best practice medical care for transgender people.

Note:Many state bans shown on this map are either not yetin efect or are temporarily blocked by court order.Transgender people should stillbe able to receive medical care until the bans go into effect. Formore information,see MAP's Equality Maps(linkedbelow).whichare maintainedinrealtime.Theyelowcautioniconrefersto stepstakenbeyond(i.e.,notincluding)introducing abilltobanorrestrict medically necessary care for transgender people. Bils are discussed in the next section. Source: MAP's Equality Maps.Data as of April 15,2023.

In each of these cases， these discriminatory and exclusionary policies are especially harmful to transgender people of color,and particularly Black transgender people. Research shows that many communities of color identify as transgender at higher rates than in white communities: for example,an estimated O.9% of American Indians, 0.7% of Latinos, and O.6% of Black adults identify as transgender, compared to 0.5% of white adults,with similar patterns among youth ages 13-17.16 This means that any discriminatory policy targeting transgender people will disproportionately harm transgender people of color.

Additionally，as Figures 2-3 show,many of these discriminatory policies are especially prevalent in the South. Because the South is home to the majority of all Black people in the United States,'7 including Black transgender people,18 the fact that these discriminatory policies are more common in the South means they disproportionately impact Black transgender people. For example, 32% of all Black transgender adults live in the 15 states that currently ban best practice medical care for transgender youth (Figure 3), compared to 28% of all white transgender adults.19,b

32% of Black transgender people live in the states with medical care bans for youth, compared to 28% of white transgender people

(As of April 15,2023)

What is Best Practice Medical Care for Transgender Youth?

It can be hard at first to understand what it's like to have a transgender child, especially for people who have never met a person (or a child) who is transgender. But parents of transgender youth, like most parents, simply want to do what is best for their child, including giving their child the best chance to thrive and be happy,and making sure their child has access to medical experts and essential medical care when they need it.

According to the CDC, just under 2% of youth ages 13-17 identify as transgender, and research shows that transgender youth understand both the idea of gender and their own internal sense of self at a very early age.For example, according to the Mayo Clinic, most children can recognize and label stereotypical gender groups by the time they are two years old,and they can recognize their own gender by the age of three."The American Academy of Pediatrics also shows that, by age four, most children have a stable sense of their own gender." This means that transgender youth likely also know their own gender, even from a young age.

When a child expresses an understanding of their gender that may not match their sex assigned at birth, there are clear standards of medical care already in place under the widely recommended and research-backed "gender afirmative model." This model refers to a set of best practices and recommendations for medical providers, parents,and caregivers of transgender youth.These standards of care center on affirming and supporting a transgender youth's gender identity with guidance from family doctors, pediatricians, counselors,and other experts in the field of medical care for transgender youth.iv

For transgender children, those who are “insistent, consistent, and persistent" about their gender identity over time, the affirming model of medical care can include beginning to live consistently as the gender they know themselves to be. For example, while each child and family has their own unique experiences, many parents report that from a young age, their transgender child has been very clear about their own gender("insistent"),such as expressing that they are or want to be a girl, and that their expression of those feelings has been generally"consistent"and held over a long period of time ("persistent"). Supporting transgender youth can include using a name and pronoun that better reflects their gender, changing hair length or style,wearing different clothes or styles,and participating in activities or using facilities in accordance with their gender. For a younger transgender child, parents typically work closely with therapists,peer support groups,school and childcare providers, healthcare providers,and others as the child navigates living in accordance with their gender.

Despite claims to the contrary, it is only once a transgender youth enters puberty that hormone-related medication may become one potential part of their recommended care.At this stage, some transgender youth-in consultation with their doctor and with the consent of their parents-may begin to take medication that temporarily delays puberty. Again,despite claims to the contrary, this medication is safe and the effects are not permanent; they simply put puberty"on pause"As a youth gets older,if they decide not to transition, they can stop taking this medication,and puberty willresume.If the young person decides to continue with their gender transition,they may later start taking estrogen or testosterone so that they willundergo puberty in accordance with their gender identity.

Why is this medication so important? Delaying puberty serves several important purposes for transgender youth.' First, this practice effectively buys time so that transgender adolescents can gain an even deeper understanding of who they are and wait to make further decisions until a later time.Second, for transgender youth,experiencing puberty and its related changes can add to or worsen already-existing experiences of intense distress and discomfort in their own bodies. Prescribed medication can therefore help protect a transgender youth's psychological and emotional wellbeing. Third, the effects of an incongruent puberty can make medical transition considerably more diffcult for those transgender youth who do later physically transition.

It should be no surprise, then,that medical research shows that transgender people,including youth, who receive best practice medical care show significant increases in self-esteem, mental health, physical health,and more.viThose who received puberty-delaying medical care during their youth were significantly les likely to have suicidal thoughts and behaviors, compared to transgender people who wanted this medication but did not receive it一even after controlling for other factors, including family support.vi In short, ensuring that families have access to this prescribed medical care is essential for the short-term and long-term health and well-being of transgender youth.

RECENT EXPLOSION OF BILLS THAT WOULD BAN MEDICALLY NECESSARY CARE FOR TRANSGENDERPEOPLE

As shown above,efforts to restrict transgender people's access to health care are not new.What is new is the near laser-focus in recent years on transgender youth and on banning medical care for transgender people entirely.

For this report, MAP identified and analyzed over 250 state bills targeting health care for transgender people since 2017.c

As shown in Figure 4on the following page, very few bills of any kind targeting transgender health care were introduced from 2017 to 2019.These bills were nearly all focused on relatively narrower restrictions,d such as not requiring insurance providers to cover best medical care for transgender people (though not banning such care either) or prohibiting state-funded health insurance (such as for Medicaid recipients) from covering such care.Only one-quarter of these bills explicitly targeted youth in some way.

In 2020,however, the number of bills seeking to ban or restrict access to transgender health care jumped dramatically-more than double the number of the previous three years combined—and,all of these bills specifically targeted best practice medical care for transgender youth,attempting to ban this care entirely. The number of these bills continued to grow in 2021,and then saw a slight drop in 2022 as states were aggressively pursuing bans on transgender children playing sports.e This slight reprieve, however, was short lived.

Just three months into 2023,more bils attacking transgender health care have been introduced than in the last six years combined. Virtually all these bills explicitly target transgender youth,though,as discussed later in this report, a growing share of these bills would also restrict access to health care for at least some transgender adults.

Figure 5 on the following page shows the parallel growth in the number of states considering these bills each year. Figure 6on page 9 shows the spread of these attacks year after year,and further shows that, from 2017 through April 2023,more than three-quarters of states (39 in total so far) have introduced a bill seeking to ban or restrict transgender health care,including 15 states and counting that have enacted a new ban.

As shown here， the volume of bills attacking transgender health care has virtually exploded in recent years.And,as discussed further in the next section, these efforts are becoming more and more extreme.

Note:"Targeting Youth" refers to bils that have youth-specific bans or restrictions,irrespective of how youth or "minor"is defined(i.e.,including bils where minor includes above age 18).
Source: MAP original analysis.Data as of April 1,2023.

Figure 5: Explosion in Number of States Targeting Transgender Health Care in Recent Years # of States Per Year Considering Bills Banning or Restricting Transgender Health Care

Source: MAP original analysis.Data as of April 1,2023.

Note: Additionaly,four states (Nebraska, Ohio,South Carolina,and Texas) have bans on best practice medical care for transgender people in their states'Medicaid program, but these bans pre-date 2017 and so are not shown in this map,which focuses on new bans or bils since 2017.

OVERTIME,TRANSGENDER HEALTHCARE BANS ARE GROWING INSCOPEAND EXTREMISM

Just a few short months into the year, 2023 has already set new records for the total number of transgender healthcare ban bills introduced (Figure 4) and the number of states considering these bans (Figure 5).These bills have also dramatically evolved and expanded in recent years,becoming more extreme over time,as this section will show.

Importantly， though thesebills often contain considerable overlap and sometimes even copycat language一again showcasing the coordinated,extremist efforts pushing these bills nationwide—these bills also vary widely. Some are relatively brief and straightforward in their proposed bans,while others span dozens of pages and contain numerous provisions to ban care,block access to any other potential avenue for care,and even enact other anti-transgender policies beyond health care.

While all of these bills seek to ban or restrict best practice medical care for at least some transgender people, this section analyzes some of the many other provisions often also contained within these bills,as well as trends over time.f Any given bill can contain multiple provisions, including but not limited to:

Banning care for transgender adults.A growing share of bills over time would also ban or restrict medically necessary care for at least some transgender adults,in addition to youth. In April 2023,Missouri became the first state to effectively ban (or at minimum,severely restrict) medical care for all transgender people.

Banning state funds for medical care.A growing share of bills include bans on state funding for health care for transgender people, such as through state employee health plans,Medicaid,and more. In many cases, these bans apply regardless of age.

Banning private insurance coverage or allowing refusals of coverage.This cuts off yet another avenue through which transgender people or their families might be able to access or afford medical care.

Criminal charges and other penalties.Bills vary in their penalties,ranging from a loss of medical license for a healthcare provider to lawsuits,criminal and/or child abuse charges,as well as a growing trend of empowering state Attorneys General to take further action to end gender-affirming care.

Expanding targets.While most bills target medical providers，more than a third of all bills from 2020 through 2023,target someone other than or in addition to medical providers—such as parents of transgender children,teachers,or even friends or neighbors.

Forced outing of transgender youth.In addition to banning care, some bills also force school staff, and sometimes any government employee, to out youth to their parent(s) if they express any thought or indication they may be transgender—often regardless of whether the home environment might be safe for that student.

Exceptions for intersex children.The large majority of these bills contain explicit exceptions allowing non-consensual surgerieson intersex children, despite proponents'purported concern for children.

Exclusionary definitions of sex.The large majority of these bills also create new,explicit definitions of sex that would effectively erase any legal recognition of transgender people,with the potential to restrict their rights throughout state law, not only in health care.

And more.Each year，new provisions emerge, illustrating the continuing efforts to both ban care for transgender people and to use these bills as a foot in the door to enact other anti-transgender provisions.

These bills vary in many ways, but they all share a common thread of allowing politicians,rather than patients and their doctors, to make medical decisions. The fact that these bils are increasingly expanding to target adults as well as youth,and to public programs as well as private individuals,is further proof that the ultimate goal is to stop transgender people from being who they are.

Growing Application to Transgender Adults

While proponents of these bills often describe their concern for children, Figure 7 on the next page shows that a growing share of these bills would also restrict best practice medical care for transgender adults ages 18 and up.

For example, in 2020,all but one of the bills applied only to transgender youth under the age of 18.The other bill (Mississippi's SB2490) applied to minors but also to transgender adults up to the age of 21.In subsequent years，as shown in Figure 7，more and more bills introduced would apply to transgender adults as well, whether through broadened definitions of"minors"(e.g, up to ages 19,21,or 26),bills with no age limits at all, or through other provisions.g

Figure 7: A Growing Share of Medical Care Ban Bils Would Also Ban or Restrict Health Care for Transgender Adults Share of Bills Each Year that Would Apply Beyond Minors (<18)

Note: "Other provisions"primarily refers to bans on state funding for medical care,regardless of the person's age. Source: MAP original analysis. Data as of April 1,2023.

Note: Some of these bans on state funds are limited to state funding for care for minors (as defined by each bil, which might include up to ages 19,21,or 26),while others have no age limit and would ban state funds from going toward medical care for alltransgender people.

In 2023,nearly three in 10 (29%) bills introduced would ban or restrict care for both transgender children and transgender adults.This includes at least 14 bills that define "minor" to include adults up to ages 19,21,or 26—more than any year before.h And in April 2023,this trend toward banning care for adults became a visceral reality，with Missouri's unelected attorney general issuing "emergency" regulationseffectively banning medically necessary care for all transgender people throughout the state.

Growing Bans on State-Funded Health Care

Many bills seeking to ban or restrict genderaffirming care would also ban the use of state funds for covering this best practice,medically necessary care for transgender people.This would ban such care from being covered in any state-funded health plan (such as for state employees or people on Medicaid) or from being provided by any even partially state-funded health provider (such as a doctor's office,clinic, or hospital that receives any state funding at all. In many cases, this would apply even to healthcare providers who do not receive state funding but whose offices are located in a government-owned building or facility.

This further illustrates the broader goal of the proponents of these bills: ending transgender-related health care entirely, thereby preventing transgender people from being their authentic selves no matter the cost.

Across all bills from 2020 to date in 2023,nearly one-third (32%) contain any ban or restriction on state funding for best practice medical care for at least some transgender people.

Figure 8 on the previous page shows that over time, these bans on state funding are becoming more common.In 2020,none of the bills contained such a provision,but by April 1,2023, nearly half (45%) of 2023 bills would ban state funds from going toward best practice medical care for at least some transgender people.While some of these provisions would apply only to care for transgender youth (as defined by that bill), a growing share apply regardless of the transgender person's age-again illustrating the broader goal of ending access to this medical care wherever possible.

In a further effort to limit access to care,even beyond state funding, some bills contain provisions about private insurance. Across all bills from 2020 to date in 2023, roughly one out of seven (14%) bills also contain at least one of the following provisions about private insurers:

Ban private insurers from covering best practice medical care for transgender minors and/or adults in their insurance plans.Without insurance coverage，most forms of health care，including transgender-related health care,are unaffordable to the average person. These provisions knowingly and intentionally seek to cut off access to medically necessary care,simply because some politicians do not like or agree with this type of health care or the people receiving it.

Ban private insurers from reimbursing the costs of best practice medical care for minors and/or adults. Banning coverage prevents insurers from paying doctors or other providers directly for this care, but in theory individuals might still be able to pay out of pocket for such care and then seek reimbursement from their insurance company.While extremely few people in the United States would be able to front the costs of their health care (and especially so for transgender people,who experience far higher rates of poverty due to discrimination),these provisions would ban this as well, cutting off yet another route for transgender people to access health care.

Explicitly allow private insurers to refuse to cover best practice medical care for transgender people, regardless of age.In this instance,private insurers may still choose to cover such care,but they are also explicitly protected if they categorically exclude transgender-related health care.This would further limit transgender people's access to medically necessary care.i

As Figure 9 shows, bills with these provisions grew dramatically from 2020 to 2022,with a decline in 2023 in the overall share of bills with these provisions. However, it is important to remember that the total number of bills in 2023 is higher than any year before, so even while the percentage of bills with these provisions has slightly decreased,the raw number of bills with these provisions has more than doubled from the year prior.

Figure 9: A Growing Number of Bills Also Ban Private Insurers From Covering Medically Necessary Care for Transgender People,or Allow Insurers to Categorically Exclude Such Care Number and Share of Bills Each Year with Private Insurance Provisions

Shifting Punishments, Including Growing Power for States' Attorneys General

Both proposed and enacted medical care bans detail a variety of punishments or potential enforcement mechanisms, including fines,lawsuits against medical providers, the revoking of a doctor's medical license or other discipline by a medical licensing board,criminal felony charges,and even charges of child abuse or neglect that could result in imprisonment or loss of custody. In many cases, these bills allow for multiple penalties or enforcement mechanisms,such as both a loss of license for a doctor and the ability for individuals to sue.

Figure 10 below shows that the most common punishment,present in the majority of bills in almost every year, is the loss of medical providers'medical license and/or other forms of professional discipline by the state's licensing board.

Figure 10 also shows that, from 2020 to 2023, the strategies behind these different penalties have shifted，illustrating the ongoing efforts of antitransgender interest groups and extremists to ban this care entirely and avoid judicial challenges to these bans.For example,over time, it is increasingly common for these bills to enable private individuals, such transgender people or their parents， to sue medical providers for providing transition-related care.The share of bills with these provisions nearly quadrupled, from 16% in 2020 to 61% in 2023 (as of this report's writing).This reflects a growing effort,as also seen in efforts to ban or restrict access to abortion, to increasingly privatize the enforcement of bans on medically necessary care,and to avoid potential judicial or constitutional challenges to these bans. These penalties are also part of a broader effort to even further discourage the provision of care in any form and to advance the incorrect claim that many people who receive transition-related care later regret it.

Figure 10: For Punishments,Majority of Medical Care Ban Bills Include Loss of Medical License,and Both Private Lawsuits and Enabling State Attorneys General are Becoming More Common Share of Bils Each Year with Each Type of Punishment or Penalty

Note: Bills can have multiple types of penalties or punishments. Source: MAP original analysis.Data as of April1,2023.

It is also becoming more common for these bills to empower states' Attorneys General to take action to enforce compliance,whetheragainst medical providers or in some cases parents and families themselves.This could take a variety of forms,including lawsuits but also other regulatory or enforcement actions.The share of bills with these provisions increased nearly five-fold, from 8% in 2020 to 40% in 2023.This illustrates with increasing clarity that one of the primary goals of these bills is to not only end access to medically necessary care for transgender people,but to also override the judgment of medical providers and instead expand the state's power to regulate the kinds of healthcare that people in the state can access.

Over this same time period,it is becoming relatively less common for these bills to define medically necessary care for transgender youth as child abuse or to prescribe criminal penalties,which can lead to imprisonment if convicted. However, it is important to remember that 2023 has seen a massive growth in the total number of bills attacking transgender health care,so even as the percentage of bills with these types of penalties decreases, the total number of bills has actually increased in 2023.

It is also important to note that many, even if a decreasing share (as shown in Figure 1O),of these bills would be enforced through the criminal and/ or child welfare systems,both of which have long and established histories of racial bias and racist outcomes.20 These systems have historically disrupted families of color, including Black and Native families, and now are moving to transgender families as well. By working in these systems, these proposed bans would likely recreate the same patterns, with disproportionate harm and family disruption coming to families of transgender children of color.

Expanding Targets From Doctors to Parents,Teachers, and More

While most bills to ban medical care for transgender people primarily target medical providers,a significant share of these bills would also or instead target parents or guardians,school or government employees,health insurers,and even friends,neighbors,or"any person"who might somehow help or assist in providing medically necessary care to transgender people，or otherwise violate the proposed law.

For example, Alabama's HB303 (2020) said that "no person"—defined to include "any individual"-shall provide,counsel, or even make a referral for best practice medical care to transgender youth,making violations a felony crime.School staff were also explicitly targeted with misdemeanor charges if they failed to out a transgender student to their parent(s),irrespective of the potential risk to the child. Oklahoma's SB345 (2023) would make it a felony crime,with up to life imprisonment, for doctors to provide medical care to any transgender person under age 21; for parents or guardians to obtain medical care for their transgender child; and even for transgender adults (under age 21) to receive care.

Across all bills from 2020 through April 1,2023,at least 35% of all bills attacking transgender health care target someone other than or in addition to medical providers.As shown in Figure 11 on the following page, in 2023 the number of these types of bills has nearly tripled from the year before.

Defining Sex, With Potentially Far-Reaching Implications

These same healthcare ban bills also frequently contain new definitions of sex that would exclude any recognition of transgender people and could potentially impact their lives in far-reaching ways.k The majority of these bils would create a new and discriminatory legal definition of sex, rooted in a person's presumed anatomy at birth or even their presumed chromosomes.'

While these provisions typically say the definitions are for the purposes of this law (i.e.， for banning medical care),these provisions would set a dangerous precedent and could likely be used to deny recognition of transgender people and their rights in other parts of the state's law, far beyond access to health care.This could impact, for example, laws about school and sports, employment，identity documents，housing，facilities access,nondiscrimination laws that include sex,and so much more.In short, if these discriminatory definitions were enacted and then applied beyond health care,even if a transgender person could access best practice medical care (perhaps outside the state),they would stillbe legally identified only by their sex assigned as birth throughout their lives—from showing identification at a restaurant to applying for a job to applying for an apartment.This would expose transgender people to even higher rates of harassment, discrimination,and even violence.m

Overall, from 2020 to 2023,more than two-thirds (69%) of these bills would create a new legal definition of sex that would exclude and harm transgender people.As Figure 12 shows,more recent medical care ban bills (those introduced in 2022-2023) are even more likely to define sex in these restrictive ways, illustrating that politicians are increasingly using these bills to attack not only transgender health care,but to attack transgender people more broadly.

Allowing Non-Consensual Surgeries on Intersex Children

Proponents of these bills argue that transgender children should not receive consensual medical care related to their sex or gender. As discussed in detail in the spotlight on page 6,best practice medical care for transgender youth doesn't begin until at least puberty, and except in rare cases, takes the form of prescription medication only,with close supervision and partnership with parents,doctors,and other experts. However, the large majority of these medical ban bills contain explicit exceptions to allow non-consensual surgeries to be performed on intersex children一surgeries that typically occur in their infancy.

"Intersex"isanumbrellatermdescribing naturally occurring differences in a person'ssex traits or reproductive anatomy， such as variations in chromosomes，hormones,or internal or external anatomy.An estimated 1.7% of people are born intersex.21 Particularly when intersex traits are noticed at birth,all too often,these children are subjected to nonconsensual surgeries to "correct" this benign difference. According to interACT, the leading organization on intersex issues, most of these surgeries happen before the age of two.22

Figure 11: Many Medical Care Ban Bills Target Not Only Doctors,But Also Parents,Teachers,Even "Any Person" Number and Share of Bills Each Year that Would Apply to Someone Other than a Medical Provider

Note: Many of these bils apply to both medical providers and other individuals,such as parents.These are minimum estimates,as many bills are vaguely written and could potentially be used to target even more people than explicitly identified in the bill. Percentages shown exclude bills that apply only to state funding,as these bills typically do not specify any penalties at all.
Source: MAP original analysis.Data as of April 1,2023.

Figure 12: Most Medical Care Ban Bills Would Define Sex in Transgender-Exclusive Ways,With Potential Implications Far Beyond Health Care Share of Bills Each Year that Define Sex In Discriminatory Ways

Source: MAP original analysis.Data as of April1,202.

Yet across all bills from 2020 through April 1, 2023,at least 81% of all bills attacking transgender health care also contain explicit exceptions that would allow surgeries on intersex children,and often do so through hyper-medicalized language implying that being intersex is a disorder that needs to be fixed or corrected. Bills without these exceptions are typically focused on adults,such as a ban on state funding or coverage of medically necessary care for transgender state employees.

As shown in Figure 13,a majority of bills in every year contain these explicit exceptions for nonconsensual surgeries on intersex children,and further that these provisions have become more commonplace since 2020.

Forced Outing of Transgender Children

While proponents of these bills argue their concern for children's safety,a growing number of healthcare ban bills would also require school staff—and in some cases, any government or public employee—to "out" transgender children to their families. Of course,schools understand the importance of cohesive families and ensuring parents are informed about their child's wellbeing; however, these forced outing provisions often apply regardless of whether this action could cause harm to the child (i.e.,a child whose family is unsupportive).This therefore undermines the ability of schools to maintain safe environments for transgender children.

For example, if a student tells a school counselor or teacherthatthey are thinking abouttheir genderidentity, or that they might like to try to use a different name or pronouns, these school staff are required to inform the child's parents,even if this information was shared in a confidential setting as with a school counselor or nurse. In some cases, these provisions can even apply if a staff person suspects a student might be thinking about their gender identity, irrespective of whether the student themselves have actually articulated any such thoughts.

In some cases,these provisions apply not only to school staff, but to any government or public employee, such as state-employed counselors, social workers, or law enforcement.This particularly impacts transgender children with a higher likelihood of interacting with state employees (e.g., transgender children in lower-income families who may have more frequent interactions with the state via social safety net programs; transgender children in the child welfare system; and more). Again, in most instances, informing parents will and does happen organically,but these laws can make it impossible to maintain a safe environment for those transgender children whose parents may react violently or abusively.

Figure 13: Most Medical Care Ban Bills Contain Exceptions for Non-Consensual Surgeries on Intersex Children Share of Bills Each Year with Intersex Exceptions

Source: MAP original analysis.Data as of April1,2023.

Figure 14: Many Medical Care Ban Bills Would Also Force School Staff,and Sometimes Any Government Employee, to Out Transgender Children

Source: MAP original analysis.Data as of April 1,2023.

Overall, from 2020 to 2023,at least 16% of all medical care ban bils contain explicit forced outing provisions.Figure 14 on the previous page shows that the number of these bills in each year has grown over time,though the share of these bills has decreased in 2023 amidst the dramatic increase in the total number of these bills.

It is important to note that many similar forced outing provisions also exist in other bills targeting schools and education, such as "Don't Say Gay or Trans" bills,so-called "Parental Rights" bills,and other school censorship bills and other attacks on LGBTQ people and issues in education. Figure 14 only shows forced outing provisions in bills specifically attacking transgender health care (i.e., not these school-focused bills),and so the true number and share of bills each year that would require or lead to the forced outing of transgender children is much higher than shown here.

Other Provisions

As stated earlier, these bills vary widely in their scope，provisions,and vitriol. As time goes on，new additional provisions are emerging. These provisions remain relatively less common than those discussed above,but may become more common as extremists continue to push these bills and other efforts to end medical care for transgender people. Examples of these other provisions-which exist in addition to the primary elements discussed above-include but are not limited to the following.

Prohibiting individuals from taking tax deductions for the costs of medically necessary care for transgender people.Generally， people can deduct out-of-pocket spending on health care when filing their taxes,assuming their spending exceeds the standard deduction.This is true for federal taxes and in some states,and federal court rulings have affirmed that medically necessary care for transgender people isan eligible, tax-deductible expense.23 However, these provisions explicitly prohibit people from deducting the costs of such care for state income tax filing—restricting yet another avenue through which transgender people might be able to afford care.

Prohibiting corporations from taking tax deductions for the costs of health insurance if it covers medically necessary care for transgender people, or for the direct costs of such care.This is intended to deter employers from providing inclusive health insurance, and further to deter employers from providing financial support to employees who may need to travel out of state to receive medically necessary care for themselves or a transgender family member.

Protectingconversion"therapy."Conversion "therapy" is a dangerous and discredited practice that attempts to change a person's sexual orientation or gender identity,and extensive research clearly shows that being subjected to this practice causes physical,mental,emotional，and spiritual harm to LGBTQ youth, in both the immediate and long term.24 Yet some medical care ban bills create explicit protections to allow conversion "therapy" to continue一again highlighting the goal of preventing transgender people from being transgender,no matter the cost to their health or well-being.

Protectingso-called"whistleblowers."These provisions would create special protections for those who report suspected violations of proposed healthcare bans.

Banning changes to the sex marker on birth certificates. Accurate and consistent identity documents help ensure transgender people can move freely and safely through their daily life,as having to show an ID that doesn't match their gender identity exposes transgender people to risk of harassment, discrimination,and even violence." These provisions would prevent transgender people from ever having anaccurate birth certificate,which in turn increases their risk of harm—again showing that the goal of these bils is ultimately to prevent transgender people from being themselves, no matter the cost.

And more， ranging frombanninginsurance companies from providing liability insurance for doctors who provide medically necessary care to transgender youth,to religious exemptions and much more.

Growing Extremism in Anti-Transgender Health Care Bills

As this report highlights, bills targeting transgender health care are both becoming more common and more extreme over time. The 2023 legislative session has brought more of these bils than in the last six years combined,as well as some of the most extreme bills seen to date. For example:

Oklahoma's HB2177 would effectively ban best practice medical care for al transgender people in the state.The bill bans medical providers from providing such care for minors,and it also bans private insurers from covering this care regardless of age.

As originaly introduced, Kentucky's 34-page HB470 seemingly combined almost every anti-transgender healthcare provision into one bil.It would have banned both best practice medical care for transgender youth,and even mental health care and social transition support. The bill banned mental health providers—including therapists, social

workers, school counselors,and more—from providing "social transition services..including but not limited to afrming the person's name change, pronoun adoption, dress and grooming,and sex-role specific behaviors that vary from those behaviors typically associated with the person's sex."While the bans on social transition and mental health care were removed in committee,the amended bills would stillban medical care for minors and state funds from providing or reimbursing care for minors, among other provisions.

Florida's S254 would allow the state to take custody of children "at risk of being subjected to"best practice, gender-affirming care, or even to take custody of children if they have a transgender sibling or parent. Even families who do not live in the state but who are visiting for work or perhaps to visit family or Disney World could have their children seized by the state.The billwould alsoallowthestate tovoid,ignore,orchangechildcustodyagreements issued by courtsin other statesifFlorida believes the child in question is"at risk"of receiving medicall necessary transgender-related care.

While not legislation, the unprecedented "emergency" regulation issued by Missouri's unelected attorney general in April 2023 represents the most extreme and comprehensive attack on transgender people's health care yet seen.The regulation effectively bans gender-affrming care for all transgender people regardless of age, though the rule will expire in February 2024 and will certainly be challenged in court before then.

Other Related Attacks on Transgender Health Care

In addition to the hundreds of state-level bills that would ban or restrict access to best practice medical care for transgender people, there are many other related efforts.These are not included in this report's bill counts or analyses,but they also work to discourage the provision of this care, protect the denial of this care, or otherwise make it harder for transgender people to access best practice medicine. For example:

· Resolutions. Resolutions typically do not carry any force of law and so are excluded from this report, but they can still contribute to the broader political environment and rhetoric about transgender people. For example, SCR3 in Texas (2023) not only condemns medically necessary care for transgender people but explicitly cals for an end to al gender-affirming care, regardlessof age. At least 20 medical care bans have been introduced in Texas in 2023 alone.

· Protecting parents who deny their transgender children best practice medical care. Parents acrossthe country already have the right to make medical decisions on behalf of their children. However, these bils specifically protect only parents who refuse to affrm or provide care for their transgender children, without providing similar protections for parents who are supportive or consent to medical care for their transgender child.See for example Indiana's HB1232 (2023)or South Dakota's SB93 (2020).

· Religious exemptions for medical providers.These bils allow medical providers to refuse to serve LGBTQ people and others if doing so might conflict with the provider's (or the provider's employer's)religious beliefs.For example,a pharmacist may refuse to fill a prescription for a transgender person's hormones simply due to the provider's personal beliefs. Already, seven States have such a law on the books, meaning that more than one in eight LGBTQ people live in states with such provisions.

· Other efforts to discourage the provision of, insurance coverage of, or even medical schools' teaching about medical care for transgender people.Many other bills don't explicitly ban this medical care,but would create new penalties or disincentives surrounding this care.For example, Florida's SB952 (2023) would require any employer whose health insurance covers gender-affirming care to also cover the costs of "detransition"care for the life of that employee, even after they are no longer an employee. Missouri's HB1332 (2023) would create a new tax on the endowments of colleges that either provide medically necessary health care to transgender minors or provide medical training on such care.

These and many more bilseek to further undermine accessto best practice medical care for transgender people, even if they do not outright ban such care.

THE IMPACTS OF EFFORTSTO BAN MEDICALCAREFORTRANSGENDER PEOPLE

It can be hard at first to understand what it's like to have a transgender child, especially for people who have never met someone who is transgender. But transgender children，like all children，do best when they are supported and given access to a safe school environment, best practice medical care,and a loving community. Similarly, parents of transgender youth,like most parents, simply want to do what is best for their child,including giving their child the best chance to thrive and be happy, including making sure their child has access to medical experts and best practice medical care when they need it.Medically necessary care for transgender youth can be different than it is for transgender adults,but in both cases, this care is backed by decades of research—and in both cases, it can be lifesaving.

Bills trying to restrict or outright ban medically necessary care for transgender people all try to take decisions away from patients, their families,and their doctors,and instead give that power to politicians and bureaucrats.People who don't have a transgender child may not understand the nuances of this medical care, but the majority of people agree that it is parents,doctors and the patient who should decide—not politicians.25 Unsurprisingly， banning such medical care entirely causes clear and direct harm to transgender people, their families and medical providers,and their broader communities.

Harm to Transgender People & Their Families

Denying anyone access to needed medical care causes harm.This is no different for transgender people. But the harms of these bills are not limited to banning best practice medical care. Even when these bills do not become law, they cause lasting damage to transgender people's health,safety,and access to health care.And,as discussed earlier and in further detail on pages 2,5,and 14,these efforts especially and disproportionately harm transgender people of color and their families.

Medical and academic research clearly illustrates that access to best practice medical care leads to better health for transgender people,across a wide range of outcomes from mental and physical health to life satisfaction and more.26,27 For example， transgender people who received puberty-delaying medication during their youth were significantly less likely to have suicidal thoughts and behaviors， compared to transgender people who wanted this medication but did not receive it—even after controlling for other factors，including family support.28 Similarly， states with transgenderinclusive healthcare policies saw higher access to care for transgender people and that such policies "meaningfully improve the mental health of transgender people."29 This necessarily means that denying this needed medical care causes harm across these same outcomes.

Research also shows that delaying care—as in the case of transgender youth who might be denied access to medically necessary care until they are adults一can still cause harm in both the short and long term.For example,research shows that transgender adults who started the medical care they needed in adolescence had better current mental health,compared to transgender adults who waited until adulthood to receive such care.30 In other words, denying care for transgender youth not only harms them while they are young,but the harm persists into adulthood,even when they are able to access needed care as adults.

Even when these bills do not become law, they can still damage or restrict transgender people's access to best practice medical care，including even basic information.For example,in Tennessee in 2022,a Vanderbilt University clinic specializing in transgender care removed from its website multiple

VE News

Hospitals Remove Trans Healthcare Information After Far-Right Attacks (click to read more)

Che New Hlork Cimes

Texas Youth Gender Clinic Closed Last Year Under Political Pressure (click to read more)

informational pages about best practice medical care for transgender people, following online harassment by far-right extremists.31 The Vanderbilt clinic later stopped offering some of its healthcare services to minors in direct response to demands from state politicians, even though no ban had yet been enacted.32 Roughly four months later,Tennessee enacted a statewide ban on best practice medical care for transgender youth.Similarly, in Texas,the largest program serving transgender youth in the state stopped accepting new patients in November 2022 amid growing political pressure from the state, particularly the state's governor and attorney general.33 Even still,in 2023,Texas is considering over 20 bills banning medical care for transgender youth (and in several cases, transgender people) statewide.

Furthermore，even when these bills do not become law, they harm transgender people and their families by fueling public debates about transgender people and their right to health care.These debates cause direct harm to transgender people and LGBTQ people more broadly,and especially youth.For example, in a national survey of youth in November 2022,71% of LGBTQ youth—including 86% of transgender and nonbinary youth—said that their mental health was negatively impacted by recent debates about antitransgender bills in state legislatures.34

Families are also impacted by these bills and the broader attacks on LGBTQ people across the country: following efforts by the Texas governor and attorney

86% of transgender and nonbinary youth

said that recent debates about antitransgender bills have negatively impacted their mental health

-The Trevor Project and Morning Consult poll,issues impacting LGTBQ Youth (2023)

POLITICO

Conservative states are blocking trans medical care. Families are fleeing. (click to read more)

general to illegally treat best practice medical care for transgender children as criminal child abuse,many families are fleeing the state.35 In Florida，which enacted its notorious "Don't Say Gay or Trans" school censorship law in 2022，a poll showed that more than half (56%) of LGBTQ parents in have considered moving out of the Florida,including more than one in six (17%) who have already taken steps to do so.36 That poll was taken before Florida enacted an administrative ban on best practice medical care for transgender youth,effective March 2023.

Harm to Medical Providers & The Broader Community

Bills attacking transgender health care impact not only transgender people and their families,but also their medical providers and the broader community. The majority of these bills create either professional or even criminal penalties for medical providers (see Figure 10 above),but the harm does not end there. Even when these bills do not become law, the fact of their introduction and consideration fuels a broader public debate about transgender people, their health care, and their healthcare providers.As a result, medical providers across the country have also come under attack.

As discussed above,multiple healthcare providers across the country have suspended their services or stopped taking new patients in direct response to the current political environment. In some cases,medical providers are now under direct attack by the state itself. For example, in Missouri,a healthcare clinic specializing in supporting transgender and gender-diverse youth isnow under both state and federal investigations following a former employee's political hit-piece in collaboration with the same national extremist groups pushing these healthcare bans nationwide. In fact, the former employee's lawyers have also worked in support of Florida's "Don't Say Gay or Trans" law,in partnership with Alliance Defending Freedom (a group classified by the Southern Poverty Law Center as a hate group),and as part of a national anti-transgender"Child and Parental Rights Campaign" seeking,in its own words, to "shield children from the impacts of gender identity ideology."37 This online publication also came at the height of the Missouri's 2023 legislative session, during which at least 10 different medical care bans were introduced—further highlighting the politically calculated timing of this effort. This illustrates the growing attacks on medical providers even outside of the legislative context.

Many providers have also reported protests, harassment,and even threats of violence and death amidst this growing attack on transgender health care.As of a December 2022 report,at least 24 different hospitals and providers across at least 21 states were directly targeted by coordinated online harassment campaigns,often led by prominent anti-transgender extremists such as “Libs of TikTok."38 These online harassment campaigns often lead to in-person protests or threats of violence, including at healthcare providers not explicitly targeted by these online campaigns.

For example,and as reported by Time Magazine,a clinic in Seattle reported anonymous hate mail as well as multiple instances of protestors on-site,noting the negative impact on the patients and families who were forced to pass the protestors on their way in to receive care.39 In Ohio，billboards placed near a children's hospital spew disinformation about medically necessary care for transgender youth.40

Again, this is true even when bills do not become law—and even when a bill is not introduced in a given state.For example, Massachusetts has yet to introduce a bill attacking transgender health care,but Boston Children's Hospital—a provider of care for transgender youth in the area,and one explicitly targeted by Libs of TikTok—has since received multiple bomb threats, leading to temporary evacuations or closures of the hospital.41 This disrupts access to health care not only for transgender people,but also for anyone else in the broader community working at or seeking care at Boston Children's Hospital—or any of the other hospitals and healthcare providers similarly targeted across the country.

Boston Children's Hospital receives bomb threat following harassment over transgender care (click to read more)

Similarly， these bills and the larger extremist movements behind them also harm the broader community by escalating anti-transgender and anti-LGBTQ rhetoric，including threats of violence. For example,in Missouri,where over 50 anti-LGBTQ bills have been introduced in 2023 alone,at least three different LGBTQ bars in the St. Louis area received bomb and shooting threats.

These examples furtherillustrate how abill introduced in one state can affect both national discussion and the ability of people in an entirely different part of the country to access best practice medical care or to go to work or simply out with friends, free from the threat of violence.

And again,these threats have direct impacts on the emotional and mental health of LGBTQ people.The earlier referenced November 2022 survey found that 75% of LGBTQ youth—including 82% of transgender and nonbinary youth—said that threats of violence against LGBTQ spaces, such as community centers, pride events, drag shows,or hospitals/clinics that serve transgender people, often give them stress or anxiety.42

PSee MAP'songoing series Under Fire(2O23)for more detail on the wide-ranging attacks on LGBTQ people across virtually every aspectoflife.

OFM

St. Louis Queer Bars Hit With Shooting, Bomb Threats (click to read more)

This report shows how bills to ban or restrict medically necessary care for transgender people are a central front of a larger war against LGBTQ people,and especially transgender people,in the United States.P Across the country,anti-transgender extremist groups, activists,and politicians are putting the lives and wellbeing of transgender people at risk by attempting to outlaw access to best practice medical care—despite this care being backed by decades of research and supported by the American Medical Association,the American Academy of Pediatrics，and every other leading health authority.

Thisreport's findings illustrate how recent bills targeting medically necessary care for transgender youth are growing in number, growing in scope,and growing more and more extreme to harm more people一 including transgender adults-than ever before.The fact that more and more bills each year also target transgender adults一and that in a growing number of cases, they would effectively ban medically necessary care for all transgender people under any circumstances, as evidenced by the recent ban issued in Missouri— reveals the extremist goals at the heart of these efforts: to prevent transgender people from existing at all.

2022numbersfromHumaRights CampaignFoundationandEqualityFederation's2StateEqualitydex(023).2023numbersfromMAPbiltracking;sealsoLGBQqualityapsUpdates: February2023"onMAP'sMediumblog.

2MAPbiltacking.Se also"LGBTQEquality Maps Updates: March 2023"on MAP's Medium blog.

3MediaMaers.February23."CandaceOwens:Thetrsaedismonic.Anactoactres,idiviualtatsupportstisissuportingsomethingthatism"

4Media Matters.November9,2022."Spotify'sJoeRogan falselyclaimsbeingtransisa'cult-like'mentalillness"

5"Promise to America's Children."2023.

Seeforexample:The American Principles Project's (2022)The Transgender Leviathan.The APP describesitselfas"the premiernational organization engaging directlyincampaignsand advocacy"and has worked directly to push anti-transgender legislation throughout the country and federally.

7Mathew Rodriguez.March 6,2023."CPAC Speaker Michael Knowles Says'Transgenderism Must Be Eradicated."Them New.

8J.DavidGoodman.March2,20."TexasCourtHaltsInvestigationofParentsOverCareforTransgenderYouth"TheNewYorkmes.

9MadisonPauly.March8,2023."InsidetheSecretWorkingGroupThatHelpedPushAnti-TransLawsAcrosstheCountry"MotherJones.

10Sforexle:adsstdrritteecciostUt

11Seforexample:KellnBaker.2017."TheFutureofransgender Coverage"TeNewnglandJournalofMedicine376(0):1801804.

1ThefirststatewdebnsontransgenderexusioswereinCalifoia(CissedAugust)andinregn("regosuraceDivisionBuletinS-"ssedecembe).

13Bianca Wilson,Lauren Bouton,M.V.Lee Badgett,and Moriah Macklin.2023.LGBTPoverty in the US:Trends atthe Onsetof COVID-19.Los Angeles,CA:The Wiliams Institute,UCLA School of Law.

14Populationestimatesoftransgenderyouthages13-17bystatearedrawnfrom:JodyHerman,AndrewFloresndKathrynO'Neil.22.HowManyAdultsandYouthldentifyasTransgedethe UnitedStatesLosAngeles,CATheWiliamsIstitute,UCLASchoolofLaw.StatelawsaredrawnfromMAP's"EqualityMaps:BansonBestPracticeMedicalCareforTransgenderYouth

15SupremeCourtofexas.May3,02."netitioforWritofandamus,IreGegbbot,JimeMastersndteexasDepartmentomilyadProtectieServices"No.29.

16Jody Herman,Andrew Flores,andKathrynO'Neil.2022.How ManyAdultsandYouth IdentifyasTransgenderintheUnited States?LosAngeles,CA:The WiliamsInstitute,UCLASchoolofLaw.

17Mohamad Moslimani,ChristineTamir,Abby Budiman,Luis Noe-Bustamante,and Lauren Mora.March 2,2023."FactsAboutthe U.S.BlackPopulation"Pew Research Center.

18Hermanesdl.

19Herman,Foresand'eil.2.SuthertatesasdefinedbytheU.S.CensusBureau's4rgioniision

20Seforexample:TeSentencingProjects(218)ReportotheUnitedNationsoRacialDisparitiesintheUS.iminalJusticeSystemndTimeagaine's (2)"neinTenBlackCildreninmrica Are SeparatedFromTheir Parentsbythe Child-Welfare System.ANew Book ArguesThat'sNo Accident."

21 interACT.2021."Intersex FAQ"

22 interACT.2021."Intersex FAQ."

23See forexample 0'Donnabhainv.Commissionerof Internal Revenue (2010).

24Seeforexample: AmericanPsychological Asociation's"FactsaboutonversionTherapy"and:WhatWe KnowProject,CornellUniversity.2016."Whatdesthescholarlyresearchsayaboutwhether conversion therapy can alter sexual orientation without causing harm?"Cornell University.

25Seefoexample:PBSewsur/RMaristpollMarch3)soingthemajoritofmericanspoemnaliggender-afingarefors

26NationalAcademiesofSience,EngineeringndMedicine (NASEM).2020."Chapter12:Coverage,AcessndUtilzationofEvidence-Bsed HealthCare"UnderstandingtheWel-BeingofLQl+ Populations.Washington DC:The National Academies Press.https://doi.org/10.17226/25877.See especially review of existing research discussed on pages 363-368.

27WatWeectellUnesit8aoaryabtfderasirasedelbelsi

28JackTurban,Dana King,JeremiCarswelland Alex Keuroghlian.2020."PubertalSuppressionforTransgenderYouthand RiskofSuicidalIdeation."Pediatrics145(2)e20191725.DOl:10.1542/peds.2019- 1725.

29Samuel Mann,Travis Campbell,andDuc-HienNguyen.2022."AcesstoGender-Affrming CareandTransgenderMental Health:Evidence from Medicaid Coverage."AvailableatSSRN.

30SeeErinDigitale January2)，Bettermentalealthfoundamongtransgenderpeoplewhostartedhormonesateens"tanfordMedicineNewsenterBasedon:Jackurban,DanaKing Julia Kobe,Sari Reisner,and Alex Keuroghlian.2022."Access to gender-affrming hormones during adolescence and mental health outcomes among transgenderadults."PLoS One 17(1):e0261039. https://doi.org/10.1371/journal.pone.0261039.

31Anya Zoledziowski.September 23,2022."Hospitals remove trans healthcare informationafterfar-rightattacks."ViCE News.

32TheAsociatedPressOctober10,2022."Vanderbiltopausegender-affrmingproceduresforminors."NBCNews.

33OrionRummler.March11,022."Politicalpressureledtohutdowofexasargestgender-ffrmingcareprogram"Th9thNews.

34heTrevredlltiacttas

35SaraErnst.April27,2022."Texasfamilies withtrans kidsare leaving the state."NPR News.

36See OrionRummlerSaraLutermanandKateSosin (February9,2023),"MorethanhalfofqueerFloridaparentshaveconsideredfleeingthestateinthewakeofDon'tSayGay'studyfinds"The19th News.Basedon:AbbieGoldberg.January2023.ImpactofHB557(Floridu'sDon'tSayGayBl)onLGBQ+ParentsinFlorida.LosAngeles,CA:TheWillamsInstitute,UCLASchoolofLaw.

37SeeMicheleunFebruary3)ceflwrsfhistebloweatStLustrasgederincantshrmotiria"Stousostspatcheseliseansrch 2023),"Familiesdisputewhistleblower'sallegationsagainstSt.Louis transgendercenter"The Missouri Independent (March1,2023).

38HumnRightsCampaign (C).December222."OnlineHarassmentOflineViolence:UnheckedHarassmentofGender-AfrmingCareProvdersandCildren'sHospitalsonocialMediadts Offline Violent Consequences."Washington DC: HRC.

39MadeleineCrlisar2.daresytceceirassmtLifnredee

41JesicaBartltt.cembr,22"BostonCdren'sfcedmonthsofdeathtreatsandhateail.re'sowtaffmemberarecoing"TeBostonGbe.

42TheTrevorjectandMongConsult.223."Nwpollmphasizesnegativeimpactsfanti-BQpicesonLBQyuth"WashngtonDC:Teevrec

ABOUT THIS SPOTLIGHT

This report is part of an ongoing series that will provide in-depth analyses of laws and policies tracked at the Movement Advancement Project's "Equality Maps"found at www.lgbtmap.org/equality-maps.The information in this report is current as of the date of publication.

MAP

movement advancement project

1905 15th Street #1097 · Boulder, CO 80306-1097 1-844-MAP-8800 www.lgbtmap.org

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LGBTQ POLICY SPOTLIGHT:BANS ON MEDICAL CAREFOR TRANSGENDER PEOPLE

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This report was authored by:

Movement Advancement Project

Acknowledgments

TABLEOF CONTENTS

EXECUTIVESUMMARY

Current Policy Landscape: Transgender People's Access to Medical Care

Recent Explosion of Bills That Would Ban Medically Necessary Care for Transgender People

Over Time, Transgender Healthcare Bans Are Growing in Scope and Extremism

The lmpacts of Efforts to Ban Medical Care for Transgender People

Conclusion

INTRODUCTION

THEIR GOAL:ERADICATETRANSGENDERPEOPLE

CURRENT POLICYLANDSCAPE:TRANSGENDERPEOPLE'S ACCESSTO MEDICAL CARE

By the Numbers: Transgender People's Obstacles to Health Care

每日获取行业报告

Nearly 1 in 5 (19%)

32% of Black transgender people live in the states with medical care bans for youth, compared to 28% of white transgender people

What is Best Practice Medical Care for Transgender Youth?

RECENT EXPLOSION OF BILLS THAT WOULD BAN MEDICALLY NECESSARY CARE FOR TRANSGENDERPEOPLE

OVERTIME,TRANSGENDER HEALTHCARE BANS ARE GROWING INSCOPEAND EXTREMISM

Growing Application to Transgender Adults

Growing Bans on State-Funded Health Care

Shifting Punishments, Including Growing Power for States' Attorneys General

Expanding Targets From Doctors to Parents,Teachers, and More

Defining Sex, With Potentially Far-Reaching Implications

Allowing Non-Consensual Surgeries on Intersex Children

Forced Outing of Transgender Children

Other Provisions

Growing Extremism in Anti-Transgender Health Care Bills

Other Related Attacks on Transgender Health Care

THE IMPACTS OF EFFORTSTO BAN MEDICALCAREFORTRANSGENDER PEOPLE

Harm to Transgender People & Their Families

Harm to Medical Providers & The Broader Community

OFM

ABOUT THIS SPOTLIGHT

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政策聚焦：禁止跨性别者接受医疗服务MAP-2023-Spotlight-Medical-Bans-report-英-29页-WN11