In 2023, there was a massive wave of legislation in states across the country to ban or restrict access to gender-affirming for transgender youth. Gender-affirming care bans targeting youth continue to be passed in 2024, with some states proposing policies that would make previously-passed youth gender-affirming care bans even more restrictive. Concerningly, multiple states this year attempted to expand their healthcare bans or move beyond restrictions impacting minors. This brief discusses some of the ways states are attempting to restrict gender-affirming care in 2024, including: 
- Expansions on previous youth gender-affirming care bans
- Policies restricting use of public funds for gender affirming care
- Administrative rules limiting access to care
- Religious exemption laws targeting gender-affirming care
The types of policies outlined in this report are “canaries in the coalmine,” warning us of a potentially dangerous future for gender-affirming care. When one state adopts a gender-affirming care policy, others tend to follow, and the policies have become increasingly restrictive over time. The policies outlined in this report warn us that conservative lawmakers are finding new legal pathways to restrict access to gender-affirming care, and that adult access to gender-affirming care is and could continue to be a target.
Expansions on Previous Youth Gender-Affirming Care Bans
In 2023, some state leaders and advocates for transgender youth and equitable healthcare were able to mitigate some of the harms of the anti-trans healthcare laws by limiting the type of care restricted and for whom care was restricted. Two such states were Georgia and West Virginia. Georgia’s 2023 gender-affirming care ban did not restrict puberty-delaying medications for youth, as most other gender-affirming care bans do. And West Virginia’s policy restricted all gender-affirming care for youth, but included a provision allowed for youth who are at risk for suicide to continue receiving gender-affirming care.
In 2024, conservative lawmakers in both states attempted to pass laws that expanded on the previously passed gender-affirming care bans, making them more restrictive. Both efforts failed. In Georgia, a bill that aimed to expand the state’s gender-affirming care ban to ban puberty-delaying medication for minors and remove the previous exemption that allowed youth who initiated care prior to the 2023 bill’s passage to remain in care did not pass the Georgia State Legislature. In West Virginia, an attempt to remove a provision that allows for youth in who are at risk for suicide to receive gender-affirming care did not pass. A similar strategy is being considered in Missouri, where the 2023 ban on gender-affirming hormone therapy and puberty delaying drugs is set to expire in 2027. Multiple bills advancing this year seek to eliminate this expiration date. Although none of these bills have passed so far, it is important to note the strategy of expanding upon previous gender-affirming care bans.
Policies Restricting Use of Public Funds for Gender Affirming Care
Many of the bans passed in 2023 were focused specifically on prohibiting gender-affirming care for transgender minors. One exception was in Florida, where the youth healthcare ban also prohibited Medicaid coverage of gender-affirming care for people of any age, and an additional provision in the same law required that any provider of gender-affirming care to people of any age be a doctor (D.O. or M.D.) This provision had an impact on transgender adults, an estimated 80% of whom were receiving gender-affirming care from a nurse practitioner or other provider.
In 2024, gender-affirming care bans have evolved, and more laws are beginning to have real impacts on trans adults. Several states already have policies that ban public funds from being used to provide gender affirming care for youth (meaning that youth cannot have their care covered by Medicaid or other state sponsored insurance, and hospitals that receive public funding cannot provide gender affirming care to youth) – but multiple states also have policies that prevent people of any age from using Medicaid or other state-sponsored insurance for gender affirming care.
A new policy just signed by the governor of Idaho takes public funding restrictions to a dangerous new level. The policy not only bans Medicaid and other state sponsored insurance programs from covering gender-affirming care, it also prevents government-owned facilities from providing gender-affirming care to both youth and adults. This policy could stand to severely limit gender-affirming care options for all transgender people in Idaho, regardless of their age.
Bans on gender-affirming care in Kansas and South Carolina have similar language as the Idaho bill regarding use of public funds for gender-affirming care. Advocates have expressed concern that the bill may intimidate providers who receive public funding away from providing gender-affirming care to patients of all ages.
Administrative Rules Limiting Access to Care
In many states, government organizations have wide jurisdiction over healthcare regulations – and in hostile states, government leaders have moved to restrict access to gender-affirming care. While these rules do not outright ban gender-affirming care, they are being used to make access to care more difficult for both youth and adults.
In March, Texas Health and Human Services implemented a new rule that prevents Medicaid from covering the cost of hormone replacement therapy for transgender people. This new rule specifically targets transgender people by listing a diagnosis of gender dysphoria as a reason for having coverage denied. States regulating Medicaid coverage of gender-affirming healthcare is not new. Nine states currently have an explicit policy stating that gender-affirming care cannot be covered by Medicaid, and many of these policies are written by state agencies that administer Medicaid, rather than state lawmakers. The new administrative rule in Texas is an indication that states are seeking to strengthen their restrictions on gender-affirming care coverage through Medicaid.
In Ohio, proposed administrative rules from the Ohio Department of Health restrict access to gender-affirming care. The original rules, which have since been revised, restricted access to care for both youth and adults, including a provision that required trans adults to get medical consent from a bioethicist before receiving care. The revised rules omit most provisions that applied to adults, focusing on restricting youth access to care beyond the restrictions already laid out in Ohio’s gender-affirming care ban for youth, HB 68, which takes effect in late April.
The proposed rules in Ohio say that trans youth can only receive care like hormone replacement therapy and puberty delaying medications at a hospital that has both a mental health professional and endocrinologist that can treat minors. They also must get six months of comprehensive mental health counseling and have an evaluation by a mental health professional before receiving care. It is already the standard of care that transgender youth must see a mental health professional before accessing treatments like puberty delaying medication and hormone replacement therapy. According to standards of care developed by the World Professional Organization of Transgender Health (WPATH), mental health providers work with youth clients individually to determine when and if a referral for medical care is necessary. A state-prescribed period of six months in therapy simply does not work for every patient.
Beyond restricting care for youth, Ohio’s administrative rule outlines reporting requirements for gender-affirming care providers. Providers will be required to report to the Ohio Department of Health when they “make a diagnosis of a gender-related condition, perform gender reassignment surgery, or provide gender-transition services.” These reporting requirements apply whether the provider is treating a youth or an adult. While reports must include the patient’s age and biological sex, names of patients will not be included, in an attempt to protect patient privacy. These data collection requirements are incredibly concerning, and some transgender rights advocates in Ohio have expressed concerns that this is an attempt by the state to gain information about transgender people in Ohio for malicious purposes.
Religious Exemption Laws Targeting Gender-Affirming Care
There is a long history of anti-LGBTQ+ laws that allow people, businesses, and more to refuse to serve people due to their personal religious beliefs or conscience. These types of laws, referred to as religious exemption bills or “license to discriminate” laws, can and have resulted in LGBTQ+ people being discriminated against or refused service in the areas of medical care, employment, education, adoption/foster care, and more. Currently, nine states have policies that explicitly allow medical providers to refuse service to LGBTQ+ people.
A new type of religious exemption law allows providers to refuse to provide certain types of medical care on the basis of their religious beliefs. These policies have potential to impact both youth and adult access to gender-affirming care.In 2023, Arkansas passed a law that explicitly says state law shall not require medical providers to provide gender-affirming care. In 2024, multiple states have proposed policies that would allow medical providers to refuse to provide services and procedures that violate their religious beliefs or conscience.
A Kentucky bill with this effect was proposed this year, although it did not pass this legislative session. In South Carolina, a proposed bill would allow pharmacists to refuse to fill prescriptions (such as hormones, puberty-delaying medications, HIV prevention medication like PrEP, birth control, and more) due to religious, moral, or ethical reasons, building on a 2022 law that grants medical providers a broad “license to discriminate.” Mississippi also proposed two religious exemption bills that would apply to pharmacists, H.B. 1069 and S.B. 2237. Both bills failed to pass the state legislature this session.
How to Take Action
In every state where gender-affirming care bans are being proposed and passed, there are local and statewide organizations working to fight these laws and provide support to transgender people. We encourage you to research and get involved with local organizations in your state.
If you don’t know how to get started, Campaign for Southern Equality’s Southern Trans Youth Emergency Project webpage provides a list of organizations who are currently partnering with us to provide support to transgender youth impacted by gender-affirming care bans.
