From Policy to Practice: How U.S. Legislation Limits Gender-Affirming Healthcare Access for Transgender Youth

Authors: Aleris Law and Lily Marino

September 2, 2025

Introduction

In the United States, the percentage of high schoolers who identify as transgender is approximately 3.3% as of 2023, reflecting increased representation and acceptance of trans people and non-traditional gender identities across recent decades. However, despite greater awareness of the existence of gender-nonconforming identities, transgender youth increasingly face reduced access to gender-affirming and potentially life-saving medical care, resulting in significant health implications for queer youth, their families, and their healthcare providers. Legislatures, particularly those in red states, are systematically eliminating access to gender-affirming care by introducing, and subsequently passing, discriminatory laws.

Supporters of transgender youth held a protest in St. Paul, Minnesota on March 6, 2022. [Image credit: Michael Siluk/UCG/Universal Images Group via Getty Images]

What is Gender-Affirming Care?

Gender-affirming care encompasses medical, psychological, and social services for transgender and other gender-nonconforming individuals. It can help relieve symptoms of gender dysphoria, i.e., the distress that results from inconsistency between gender identity and sex assigned at birth. Most major U.S. medical associations recognize that gender-affirming care is a medical necessity, helping trans people live safe and healthy lives by significantly decreasing the prevalence of depression and suicidal tendencies. Conversely, denial of these services can have detrimental effects.

History of Gender-Affirming Care

Gender-affirming medical treatment originated in early 20th century Germany, pioneered by Magnus Hirschfeld, a German-Jewish physician who researched sexuality and gender. In 1919, he founded the Institute for Sexual Science (Institut für Sexualwissenschaft), where the first documented use of genital surgery, an orchiectomy, was performed in 1922; this feat was later followed by penectomy and vaginoplasty, both performed in 1931. The first facility of its kind, the Institute for Sexual Science provided medical care, professional training, and research opportunities to the surrounding community. It also served as a library, residence, and community center. 14 years after its inception, the Institute was destroyed, fueled by Nazi ideology and the belief that “life unworthy of life” (Lebensunwertes Leben) should be removed from Germany. Homosexuals and transgender people were included among the condemned, and Nazi propagandists used Hirschfeld as an example of “degenerate Jewish sexuality” and “un-German culture.”

Gender-affirming care first emerged for Americans in the 1940s but was mostly limited to patients who could afford to travel to Europe. Christine Jorgensen, the first American to undergo a sex change operation, brought attention to transgender stories in 1952, but even she had to travel to Denmark for treatment. Finally, in 1966, Johns Hopkins Hospital became the first academic institution in the U.S. to offer gender-affirming surgery, influenced by Dr. Harry Benjamin’s book, The Transsexual Phenomenon, published that same year. Benjamin, who had been studying transgender issues since the 1950s, had also previously spent time at the Institute for Sexual Science. His coverage and study of gender-affirming care laid the foundation for modern transgender healthcare.

The Johns Hopkins clinic operated for more than 13 years, finally closing in 1979 after a study, though flawed, presented evidence that gender-affirming surgery did not provide “objective” benefit for transgender individuals. In response, the World Professional Association for Transgender Health (WPATH), originally founded as the Harry Benjamin Gender Dysphoria Association, created the first version of Standards of Care for the Health of Transsexual, Transgender, and Nonconforming People, establishing standardized guidelines for gender-affirming medical services.

In 1980, the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM) recognized “transsexualism” and “gender identity disorder of childhood,” which helped promote transgender individuals' access to healthcare. The 5th edition of the Manual, DSM-5, replaced “gender identity disorder” with “gender dysphoria” in 2013, further destigmatizing the diagnosis.

History of Gender-Affirming Care in Adolescents

The first program with a specific focus on treating adolescents with gender dysphoria was established in the Netherlands in 1987 under Dr. Peggy Cohen-Kettenis, where the “Dutch Protocol” was developed. Based on the WPATH’s Standards of Care for treating transgender adults, it recognized the importance of preventing progression of puberty that could exacerbate gender dysphoria. If a comprehensive psychological assessment established a diagnosis of gender dysphoria, pre-pubertal patients could then undergo treatment with a gonadotropin-releasing hormone agonist (GnRHa) to pause pubertal development. During pubertal suppression, patients could further explore their gender identity before committing to further hormone therapy — this could include estrogen or testosterone at around 16 years of age and gender-affirming genital surgery at 18 years or older.

This protocol was adapted internationally, but the first formal U.S. treatment program for transgender adolescents, the Gender Management Service, was only established in 2007 at Boston Children’s Hospital by Dr. Norman Spack. The clinical protocols at the Gender Management Service were developed through a combination of direct observation, reference to the Dutch Protocol, and previous guidelines from the WPATH’s Standards of Care. Since then, the number of recognized pediatric/adolescent gender-affirming care programs in the U.S. has ballooned to 60 as of March 2022, with a probable number of smaller programs and individual offices also providing care. However, the ability of transgender youth to access such programs is increasingly at stake, as some programs are beginning to close due to political reasons.

U.S. Legislation Impacting Gender-Affirming Care

The Trump administration has been central in the shift towards anti-trans attitudes in the U.S. At the very start of his second term, President Trump began to issue a multitude of executive actions that directly affect programs and policies initiated for the health of LGBTQ+ people. These orders include the recession of executive orders and actions issued by President Biden that previously called for LGBTQ+ people’s health equity, data collection, and national public health needs, as well as nondiscrimination protections in healthcare and education; the definition of sex as an immutable binary biological classification and removal of recognition of the concept of gender identity in government agency operations; and the requirement for agencies and programs to work towards significantly limiting access to gender-affirming care for young people.

These orders have had wide-reaching effects that extend beyond the LGBTQ+ community. Per Executive Order 14168 (“Defending Women From Gender Ideology Extremism And Restoring Biological Truth To The Federal Government”), many government agencies took down thousands of healthcare webpages and datasets with references to what the Executive Order calls “gender ideology,” making it harder for healthcare providers to properly treat even patients who are not LGBTQ+. In July 2025, a U.S. district court finally ordered the U.S. Department of Health and Human Services (HHS) to restore some of these pages; however, they were appended with disclaimers that the published information does not “reflect biological reality.” Judge John Bates did not prevent the administration from trying to remove the webpages again, potentially allowing more chances to pass legislation targeting gender-affirming care and resources.

Overall, 2025 is the sixth consecutive record-breaking year for the total number of anti-trans bills being considered in the U.S. As of August 2025, out of 969 bills being considered this year, 121 bills have already passed, with 116 signed into law. These bills purport to “protect children,” with titles such as the Protect Children’s Innocence Act and Protecting Children from Experimentation Act and language such as “genital mutilation” and “chemical castration.” Evidence strongly suggests that the models of care these bills would allow could severely harm transgender youth for the rest of their lives.

As of June 2025, 40% of trans youth ages 13 to 17 live in one of the 27 states that have enacted laws/policies limiting youth access to gender-affirming care. These policies prohibit healthcare professionals from providing or referring minors for hormone therapy, puberty-blocking medications, and gender-affirming surgeries; forbid use of public funds, including Medicaid funding, for gender-affirming care for minors; and modify custody laws to permit the state to take physical custody of a child who is present in the state and "at risk of or is being subject to" gender-affirming care.

The Role of the U.S. Court System

As the number of states enacting such policies increases, the number of related lawsuits follows suit. Individuals have turned to the U.S. court system to appeal or to gain a more consistent framework in the face of huge discrepancies between state policies. In Texas, Governor Greg Abbott instructed the Texas Department of Family Protective Services to begin investigating the provision of gender-affirming care to minors as child abuse in 2022. Several families with transgender children filed for a temporary injunction against the enforcement of this order, which was granted by a district court. In Florida, the Florida Board of Medicine adopted new standards of care in November 2022 that prohibited the provision of gender-affirming care to transgender adolescents. A preliminary injunction was granted in 2023, temporarily preventing enforcement of the ban, but the U.S. Court of Appeals for the 11th Circuit overturned the decision in August 2024, removing the injunction and allowing enforcement of the ban to resume as the case progressed.

In a startling escalation in June 2025, the U.S. Supreme Court heard and ruled on a case originating in Tennessee titled United States v. Skrmetti. The plaintiffs — three transgender minors, their parents, and a doctor — argued that a 2023 Tennessee law restricting sex transition treatments for minors violated their Fourteenth Amendment rights. This claim relies heavily upon a 2020 Supreme Court Ruling which established that discrimination of transgender people as a class ought to be considered discrimination on the basis of sex. The 2023 Tennessee law they are opposing, S.B.1, states that doctors can neither administer puberty blockers and hormones nor surgically alter a minor for the purpose of developing an identity “inconsistent with the minor’s biological sex.” 

The case was argued before the Supreme Court in December 2024, and the ruling of the court was expressed in a majority opinion authored by Chief Justice John Roberts. The ruling found that the three minors’ Fourteenth Amendment rights were not being violated. In order for S.B. 1 to be considered unconstitutional, it would have had to discriminate against an established class without good governmental reason. 

The Court found that S.B.1 incorporates two classifications: 1) age — individuals under 18 are subject to this law, and 2) medical use or purpose — hormones and puberty blockers may still be used to treat maladies unrelated to gender dysphoria, like a congenital defect such as hirsutism, excessive male pattern hair growth in females. Because neither of those classifications are dependent on the protected class of sex, the court ruled that the law does not violate the Fourteenth Amendment. A dissenting opinion written by Justice Sonia Sotomayor argued that if an individual with a biological sex of male can be treated with testosterone to supplement male traits but an individual with a biological sex of female cannot, that makes it an issue of sex discrimination. 

Impacts of Anti-Transgender Legislation

The Supreme Court’s national jurisdiction means that the ruling for United States v. Skrmetti is no longer restricted to the state in the case itself. As a result, this most recent ruling protects the 26 other states that have laws on withholding transgender care for minors — as long as they stick to the classifications established in Tennessee — and serves as a major setback for trans people’s rights and well-being. 

The criminalization of pursuing or providing gender-affirming care for minors, even if not surgical, could have devastating consequences. Transgender youth experience disproportionate levels of violence, bullying, and social ostracization compared to cisgender youth, whose gender identities are consistent with their sex assigned at birth. More than a third (34.6%) of transgender high school students who completed a 2017 survey reported attempting suicide in the prior 12 months, which is four to six times the rate reported by their cisgender peers. Comparatively, transgender youth who have access to gender-affirming medical care largely show improvements in mental health, with mental health status often comparable to their cisgender peers. 

Anti-transgender legislation also puts family members of transgender youth at risk by penalizing or holding liable the parents who facilitate minors’ access to gender-affirming care. The classification of some forms of gender-affirming care as “genital mutilation” or even “child abuse” could likely dissuade otherwise supportive family members from pursuing treatment for their child, with potential loss of custody serving as a major deterrent. 

Not only will transgender minors and their families face restrictions, healthcare providers and other public employees might be required to disclose if a young person seeks affirmation of a gender that differs from their sex assigned at birth. Medical practitioners who provide gender-affirming care for minors or refer them and their families externally could face discipline from state licensing boards and potentially lose their ability to practice medicine, even if they intend to act in the best interest of their patients.

In her dissent to the majority opinion in United States v. Skrmetti, Justice Sonia Sotomayor therefore asserts that the Tennessee law not only takes options for healthcare away from transgender minors, but from their parents and doctors as well. In an ironic twist, it was parental rights that President Trump proclaimed to be defending in an Executive Order on January 29, 2025 (“Ending Radical Indoctrination in K-12 Schooling”), and it is parental rights that the Secretary of Health and Human Services, Robert F. Kennedy, Jr., touted when he discussed an end to vaccine requirements. 

What’s Next?

As the policy landscape continues to shift, it is paramount that we continue advocating for transgender youth and educating the public about their specific needs. Legislation currently being considered by state and federal governments across the U.S. will criminalize appropriate, individualized medical care for transgender youth, putting their mental and physical well-being at serious risk. It is our collective responsibility to ensure that future generations of queer individuals thrive in a world that values their dignity and right to compassionate, evidence-based care.

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Glossary

• Chemical castration: most commonly used as a treatment for cancer in the testes or ovaries, this is the use of chemicals or drugs to stop sex hormone production; in the context referenced in this article, the phrase is being used with a highly negative connotation to suggest that the repression of sex hormones as a treatment for gender dysphoria is unnatural. 

• Cisgender: describing or relating to a person whose sex assigned at birth corresponds with their gender identity. 

• Congenital defect or anomaly: an abnormality of body structure or function present at birth and of prenatal origin. They can arise as a result of environmental, hormonal, or genetic factors, and some are never attributed to any specific etiology. 

• Gender-affirming care: medical, surgical, mental health, and non-medical services for transgender and gender-nonconforming people.

• Gender-affirming surgery: surgery that gives transgender or gender-nonconforming individuals the physical appearance of the gender they identify as.

• Gender dysphoria: a psychological diagnosis wherein an individual experiences a marked incongruence between the sex assigned to them at birth and their experienced/expressed gender, causing that individual clinically significant distress or impairment in daily life.  

• Gender identity: a person’s internal sense of being male, female, or something else.

• Gender non-conforming: denoting or relating to a person whose behavior or appearance does not conform to prevailing cultural and social expectations about what is appropriate to their sex assigned at birth.

• Genital mutilation: most commonly practiced against women, this is the — often forceful — partial or total removal of external genitalia, which has no health benefits and often causes later health issues. It is frequently used as a method for maintaining suppression of women. In the context referenced in this article, individuals are equating gender-affirming surgery with genital mutilation in an effort to paint gender-affirming surgery as cruel and dangerous. 

• Gonadotropin-releasing hormone agonist (GnRHa): an artificial agonist which mimics the natural gonadotropin-releasing hormone (GnRH). GnRHa binds to the body’s GnRH receptors, causing an initial increase in estrogen or testosterone before it causes desensitization, resulting in a decreased production of sex hormones (estrogen and testosterone). In the case of pre-puberty hormone treatment, this allows for the suppression of natural puberty, allowing for more flexibility in gender-confirming treatment down the road. 

• Homosexuals: individuals who experience sexual and romantic attraction to others of one’s own gender. 

• LGBTQ+: literally standing for “lesbian, gay, bisexual, transgender, queer, plus,” this acronym is frequently used to refer to the wide community of those who identify as something other than cisgender and heterosexual.  

• Maladies: a disease or disorder of the body.

• Nonbinary: a gender identity ascribed to someone who rejects the traditional binary nature of gender; they identify as neither male nor female. 

• Orchiectomy: a surgical procedure that removes one or both testicles.

• Penectomy: a surgical procedure that removes the penis.

• Provision: the act of providing a good or service.

• Sex assigned at birth (SAAB): the characterization of a person’s sex – either “male” or “female” – assigned to every individual at the time of their birth based on the physical appearance of their genitals, their chromosomal makeup, and their hormone levels. 

• Sex change operation: a medical operation that alters an individual's anatomical gender indicators. These can include an orchiectomy, a penectomy, top surgery (removal of breast tissue), and others. 

• Social ostracization: the act of excluding or ignoring someone, either intentionally or unintentionally, by an individual or a group. 

• Temporary injunction: a court order that prohibits a party from taking a specific action, or requires them to take a specific action, for a limited time, usually until a final decision is made in a legal case. It preserves the status quo until the case can be judged on its merits. 

• Transgender: refers to someone whose gender identity does not match the sex they were assigned at birth. 

• Vaginoplasty: a surgical procedure that creates a vulva and vagina.