Summary

This care was lifesaving. We didn't know it was lifesaving until it was gone.

— Sarah, mother of a 17-year-old trans girl in a state with a ban in place, April 8, 2024

Since 2021, a wave of legislation targeting transgender health care has swept across the United States, with 25 states enacting blanket bans on gender-affirming care for transgender youth as of March 2025. These legislative bans, often vague and sweeping in scope, have disrupted healthcare access for over 100,000 transgender youth, and imposed significant geographic, financial, and emotional burdens on their families.

The election of President Donald Trump in November 2024 has deepened the crisis facing transgender youth and their families. In early 2025, the administration launched a series of executive actions amounting to a federal assault on transgender people’s rights.

This report, based on 51 interviews with transgender youth, parents, healthcare providers, and advocates across 19 states, examines the far-reaching impacts of legislative bans on gender-affirming care for transgender youth in the United States, documenting the cascading effects on individuals, families, healthcare systems, and communities.

Gender-affirming care encompasses a set of social, medical, and psychological interventions that help transgender individuals align their gender identity with their physical bodies. It is a personalized, holistic, and iterative process tailored to the unique needs of the individual. Evidence shows that this care significantly reduces suicidality and provides long-term mental health benefits. Nearly all transgender youth continue their care into adulthood, most studies show, and satisfaction rates are high. Despite its proven efficacy, legislative bans have disrupted or denied access to this health care, replacing nuanced medical decisions with blunt, all-encompassing restrictions.

In interviews conducted after the bans were enacted, healthcare providers described to Human Rights Watch how their previous gender-affirming care practices had been tailored to each patient's needs. They emphasized the importance of working in multidisciplinary teams that often included pediatric subspecialists, mental health professionals, and social workers. This collaborative approach ensured that care was both medically appropriate and supportive of the patient's overall well-being, addressing not just physical health but also social and emotional needs.

The Harms

The consequences of losing access to gender-affirming care have been catastrophic for thousands of transgender youth and their families. Families reported instances of abruptly losing access to care, as clinics closed or reduced services, forcing repeated disruptions in treatment and exacerbating mental health crises for transgender youth.

As an 18-year-old trans woman whose care was interrupted by a state ban put it: “I want [lawmakers] to know they’re ruining people’s lives.”

Families interviewed described the burdens imposed by these bans, including geographic and financial challenges in accessing care. Eleven families told Human Rights Watch they were compelled to travel out of state—often making regular trips to consult physicians, or obtain prescriptions. Four youth were unable to begin care due to legal barriers combined with geographic and financial obstacles. One family relocated to another state to secure reliable access to care and escape an environment hostile to trans people.

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Parents reported traveling long distances, sometimes across multiple states, incurring costs for airfare, gas, hotels, and lost wages. Two families reported having to re-establish care twice as new bans forced them to relocate again. Families and advocates reported that insurance companies routinely deny coverage for out-of-state treatment, forcing families to bear significant financial burdens. Some families reported facing costs of up to US$4,500 every six months for medications alone. These challenges disproportionately impact low-income families and rural residents, who often lack the resources to afford regular interstate travel for care.

The reported mental health toll of these bans on transgender youth is particularly severe. A 2024 Trevor Project study found that suicide attempt rates among transgender youth increased by as much as 72 percent in the first year after the adoption of state-level anti-transgender laws. Families interviewed for this report described seven incidents of suicide attempts or ideation directly linked to legislative bans, with three resulting in hospitalization. Even for youth who retained access to care, the hostile legal and political environment has exacerbated feelings of anxiety, depression, and isolation.

The bans have created a healthcare crisis, deepening existing disparities in access to medical services, as healthcare providers reported being forced to reduce or end gender-affirming care options. Six states classify the provision of gender-affirming care as a felony offense. Eight states have vague “aiding and abetting” provisions that restrict providers from facilitating gender-affirming care, which could include offering referrals or medical records, discussing out-of-state treatment options, refilling prescriptions, or even running lab tests. The opaque wording of many of these laws has led to “overcompliance,” where providers restrict more care than may be legally required out of fear of legal repercussions.

Most states with bans had already faced severe shortages of pediatric subspecialists before the bans were enacted. In particular, low-income families, people of color, and rural residents have faced compounded barriers to accessing care. Currently, twelve states prohibit Medicaid coverage for transgender youth seeking such care, and ten of these states extend this exclusion to all transgender people regardless of age. Families in states where Medicaid coverage is excluded for transgender youth reported facing high costs, with some quoted up to $26,000 every three months for necessary medications.

Healthcare providers offering gender-affirming care have become targets of harassment and violence. Since 2022, clinics and hospitals have reported bomb threats, arson attempts, and coordinated harassment campaigns. Providers have reported receiving death threats, having their personal information exposed online, and being forced to implement costly security measures. This climate of fear has driven many providers to cease offering care or relocate to states with more supportive policies, further reducing access to gender-affirming care for transgender individuals. The targeting extends to civil society organizations, with many canceling events or significantly increasing security. One Pride organization reported quadrupling its security budget due to escalating threats.

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In response to the escalating threats, in 2022 the American Academy of Pediatrics, the American Medical Association, and the Children’s Hospital Association—representing over 270,000 physicians—wrote a public letter to then-US Attorney General Merrick Garland urging the Department of Justice to investigate and prosecute those threatening violence against children’s hospitals and physicians providing gender-affirming care.

Every gender-affirming care provider interviewed by Human Rights Watch reported experiencing some form of anti-trans harassment—whether directed at themselves or their place of work—through phone calls, emails, social media, or mail.

The state of Texas is an extreme example of the weaponization of child welfare services against families supporting transgender youth. The state attorney general has reportedly sought medical records of transgender patients and launched investigations into healthcare providers, creating a climate of fear that has driven many families underground and into hiding. Parents said they feared routine medical appointments could trigger investigations for child abuse. Some families reported avoiding healthcare interactions altogether to protect their children, whose identity as trans, if disclosed, could trigger child abuse investigations.

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In many states, anti-transgender rhetoric with implicit threats of violence lead healthcare providers and trans rights advocates to relocate conferences, remove online resources, and curtail research into transgender health. One provider described the systematic erosion of knowledge and the visibility of transgender people’s lived experiences from public discourse as a “21st-century book burning.”

On January 28, President Trump signed an executive order titled “Protecting Children from Chemical and Surgical Mutilation,” which prohibits federal funding for institutions that provide or research gender-affirming care for anyone under 19, cuts off access through federal health programs, and directs agencies to investigate and penalize providers. In response to the order, several clinics in states where care remains legal have preemptively suspended services for youth. Legal challenges to the executive order are ongoing.

The Context

In 2024, the Supreme Court heard oral arguments in U.S. v. Skrmetti, a case challenging Tennessee’s gender-affirming care ban, which selectively prohibits care for transgender youth while allowing identical treatments for cisgender youth. The case, expected to be decided in 2025, will determine whether such bans violate the Equal Protection clause of the Fourteenth Amendment to the US constitution, potentially influencing similar laws nationwide.

State legislative bans on gender-affirming care are part of a broader web of anti-transgender legislation targeting multiple aspects of transgender people’s lives. In addition to bans on care, as of May 2025, 28 states have prohibited transgender youth from participating in sports consistent with their gender identity; 19 states have restricted transgender youth from using bathrooms aligned with their gender identity in K-12 schools; 19 states have censored discussions of sexual orientation and gender identity in school curricula; and 8 states have mandated that school officials disclose students’ transgender identity to parents.

In recent years, the United States has witnessed an increase in anti-transgender rhetoric and messaging. In the 2024 election cycle alone, right-wing politicians invested nearly $215 million in anti-trans network television advertisements, a figure that excludes spending on print, online, cable, and other broadcast media.

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The rise in anti-transgender legislation has coincided with an escalation in violence against transgender individuals, even as violent crime overall decreased by approximately 3 percent from 2022 to 2023. Federal Bureau of Investigation data shows that gender identity-based hate crimes are on an upward trend, increasing from 307 offenses in 2021 to 515 in 2022, reaching 547 in 2023, the latest year for which complete data is available.

At the federal level, the Trump administration escalated attacks on transgender people’s rights. In early 2025, in addition to the ban on federal funding for gender-affirming care for youth, the administration issued a series of other executive orders targeting education, military service, and legal recognition for transgender people. These actions have fueled a nationwide climate of fear, deepened anti-trans hostility, and created a chilling effect across various sectors of daily life. In interviews conducted after the inauguration of President Trump, several individuals expressed fears for their safety and the increasing threats to gender-affirming care.

Remedies

The cascading effects of these legislative bans on transgender youth, their families, and the broader healthcare system require urgent intervention. Less than half of US states have enacted comprehensive statutory protections against discrimination based on sexual orientation and gender identity. The United States lacks comprehensive federal legislation explicitly protecting LGBT people from discrimination in areas such as education, housing, public accommodations, and federally funded programs.

Recommendations for addressing this crisis include action at multiple levels: state legislatures should repeal existing bans on gender-affirming care and ensure Medicaid coverage; Congress and state lawmakers should enact comprehensive federal non-discrimination protections; federal and state agencies should enforce existing civil rights protections to protect transgender people from discriminatory treatment; and the executive office should rescind executive orders that deny rights and recognition to transgender people and undermine access to gender-affirming care.

Glossary

Aiding and Abetting Clauses: Provisions in numerous pieces of legislation banning gender-affirming care that outlaw providers from facilitating gender-affirming care, sometimes interpreted to include providing medical records or referrals, discussing out-of-state treatment options, refilling prescriptions, or running lab tests.

Cisgender: The gender identity of people whose sex assigned at birth conforms to their identified or lived gender.

Conversion Practices: Deliberate efforts to change someone's sexual orientation or gender identity, rejected as harmful by leading medical organizations. These practices, which can occur in medical, religious, or commercial settings, have been linked to severe mental health consequences.

Deadnaming: The act of referring to a transgender or non-binary person by their birth name or previous name after they have transitioned.

Detransition: To stop receiving gender-affirming care and return to living as one’s gender assigned at birth.

Disinformation: False information designed to deliberately mislead people.

Dysphoria: A significant distress from the discordance between one’s sex assigned at birth and one’s gender identity.

Doxxing: Publishing personally identifiable information about an individual without their consent, sometimes with intent to provide access to them offline, exposing them to harassment, abuse, and possibly danger.

Gender: The social and cultural codes used to distinguish between society’s conceptions of “femininity” and “masculinity.”

Gender-Affirming Care: A set of social, medical, and psychological interventions that help transgender and non-binary individuals align their physical bodies with their gender identity.

Gender-Affirming Care Bans: Laws that severely restrict or criminalize the provision of medically facilitated gender-affirming care.

Gender-Affirming Care Provider: A medical professional who offers a range of services to affirm the identities of transgender and non-binary people. Gender-affirming care providers come from a variety of medical disciplines. Some providers treat patients at clinics dedicated to the provision of gender-affirming care, while others integrate gender-affirming care into their wider practice.

Gender Euphoria: A feeling of happiness, joy, or relief individuals experience when their gender is presented and/or received in accordance with their gender identity.

Gender Expression: The external characteristics and behaviors that societies define as “feminine,” “androgynous,” or “masculine,” including such attributes as dress, appearance, mannerisms, hairstyle, speech patterns, and social behavior and interactions.

Gender Identity: Social and cultural codes used to distinguish what a society considers “masculine” and “feminine” conduct and/or characteristics. Gender is also an identity and refers to a person’s internal, deeply felt sense of being female, male, both, or something other than female or male. It does not necessarily correspond to the sex assigned or presumed at birth.

Gender Non-Conforming: Behaving or appearing in ways that do not fully conform to social expectations based on one’s assigned sex at birth.

Grandfather Clause or Grandfathered Patients: Exemptions in multiple state gender-affirming care bans that allow youth who were receiving gender-affirming care prior to the enactment of the law to continue accessing this care in-state.

Hormone Therapies or Hormone Replacement Therapies (HRT): Medical treatment where individuals take sex hormones (estrogen, testosterone blockers, or testosterone). Hormone therapies are used to treat a variety of medical conditions and can be used as a part of gender-affirming care.

Intersex: An umbrella term that refers to a range of variations in chromosomes, gonads, and/or genitals that vary from what is considered typical for female or male bodies. A former medical term, “intersex” has been reclaimed by some as a personal and political identity. Intersex is not the same as transgender, which describes individuals whose gender differs from the sex they were assigned or presumed at birth.

LGBT: Lesbian, gay, bisexual, and transgender; an inclusive term for groups and identities sometimes also grouped as “sexual and gender minorities.” The acronym may also include “I” for “intersex” or “Q” for queer.

Misinformation: The inadvertent spread of false information with no specific intent to harm.

Misgendering: The act of intentionally or unintentionally referring to a person with language, such as a name or pronoun, that does not align with their gender identity.

Non-Binary: The gender identity of people who identify as not exclusively men or women. Non-binary people may identify with a mix of genders, somewhere in between them, or neither. They may use a range of pronouns.

Outing: The act of disclosing a lesbian, gay, bisexual, or transgender person’s sexual orientation or gender identity without that person’s consent.

Passing: When someone is perceived as a gender they identify with.

Puberty Blockers: Medications, primarily gonadotropin-releasing hormone (GnRH) agonists, that temporarily pause puberty by suppressing the body’s production of sex hormones. They are used to treat a variety of conditions and can be used as a part of gender-affirming care.

Sex: Classification of bodies and people (often at birth) as female, male, or other, based on biological factors such as external sex organs, internal sexual and reproductive organs, hormones, and chromosomes.

Stealth: A transgender person choosing to live as the gender they identify with without making their transgender status public.

Telehealth: The provision of health care remotely by means of telecommunications technology.

Transgender: The gender identity of people whose sex assigned at birth does not conform to their identified or lived gender. A transgender person usually adopts, or would prefer to adopt, a gender expression in consonance with their gender identity but may or may not desire to alter their physical characteristics to conform to their gender identity.

Transgender Men or Boys: Persons designated female at birth but who identify and may present themselves as men or boys.

Transgender Women or Girls: Persons designated male at birth but who identify and may present themselves as women or girls.

Transmasculine: A broad term used by people assigned female at birth who identify with masculinity, regardless of their gender identity. The term may be used by non-binary people, gender non-conforming people, transgender men, and others.

Methodology

Human Rights Watch conducted research for this report between December 2023 and March 2025. Interviews were conducted with individuals living in 19 states, 13 of which had passed bans on youth access to gender-affirming care. These states included Alabama, California, Connecticut, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Missouri, Minnesota, New York, North Carolina, North Dakota, New Jersey, Ohio, Oregon, Tennessee, and Texas.

The research was carried out in an increasingly hostile environment for transgender individuals and their families. The chilling effect of recent legislative measures, combined with heightened anti-trans rhetoric and incidents of harassment, impacted data collection. Many potential participants declined to participate despite assurances of anonymity, citing fears of retaliation from both state authorities and private individuals or groups. This climate of fear was pronounced in states that had recently enacted restrictive legislation and extended to healthcare providers across state lines who treat patients from these jurisdictions. Medical providers expressed concern about potential legal liability, professional consequences, and personal safety risks, regardless of their own location, if they were known to provide care to patients from states with restrictive laws.

To identify research participants, Human Rights Watch conducted outreach through state and local LGBT rights groups, gender-affirming care providers, and organizers who shared information about the research project with affected individuals. Human Rights Watch also published a call for participation that was shared by local LGBT organizations on social media platforms. The researcher also conducted outreach within virtual networks of gender-affirming health-care providers to identify clinicians and patients willing to participate in the research.

Human Rights Watch conducted a total of 51 interviews: 14 with transgender youth under the age of 22 (4 of whom were 18 or older at the time of their interview), of whom 7 identified as trans women or girls, 4 as trans men or boys, and 3 as non-binary individuals; 16 interviews with parents of transgender youth, including 4 instances in which parents and children were interviewed together at the family’s request; 11 interviews with doctors and other gender-affirming healthcare providers working with youth from a range of disciplines; and 10 interviews with organizers working with affected trans communities, two of whom were also parents of trans youth. The research also included other consultations with 32 LGBT rights organizers in 21 states, 18 of which had passed bans on gender-affirming care.

Forty of these interviews were conducted in 2024 to document the impact of state-level restrictions on gender-affirming care. In 2025, following the inauguration of President Trump, an additional 11 interviews were carried out to examine the early impacts of the administration’s executive orders, particularly on transgender youth’s access to gender-affirming care.

All interviews were conducted virtually. The researcher obtained verbal informed consent or assent from interviewees, ensuring they understood the purpose of the research, how their testimony would be used, and their right to decline questions or terminate the interview at any time. Participants were not compensated for the interviews.

To protect their privacy and mitigate the risk of adverse consequences for participating in the research, pseudonyms are used for all interviewees in this report. Given the heightened risks faced by participants and their families, additional identifying details, such as state names and dates affiliated with specific pieces of state legislation, have been withheld to further protect participants’ identities.

This report reflects the experiences of individuals who were willing and able to share their stories despite significant risks, resulting in certain research limitations. For instance, the report primarily reflects the perspectives of families who are supportive of their transgender children. This support, while vital, is not universal; many transgender youth face rejection from their families, which can exacerbate barriers to care and increase vulnerability. The experiences of unsupported youth are underrepresented due to the challenges of safely reaching this population. In addition, the research focuses largely on the experiences of those directly navigating the impacts of gender-affirming care bans. It does not claim to provide a comprehensive account of all transgender individuals affected by these laws, particularly those who remain disconnected from community networks or healthcare systems.

While 27 states have implemented legislative restrictions on gender-affirming care for youth, only two states—New Hampshire and Arizona—have specifically limited their bans to gender-affirming surgeries for those under 18 years old. The remaining 25 state laws, referred to in this report as "bans" or "blanket bans," prohibit nearly all forms of gender-affirming medical care for those under 18 years old, including access to puberty blockers and hormone therapies. Given the exceedingly rare occurrence of gender-affirming surgeries on those under 18 years old, as discussed in more detail in the following section, laws solely targeting these procedures have been excluded from our definition of gender-affirming care “bans.”

This report does not seek to provide an exhaustive account of all aspects of transgender health care or the lived experiences of all transgender youth. It is not a comparative analysis of healthcare systems in states with and without bans. Instead, it focuses specifically on the documented impacts of legislative restrictions on gender-affirming care for transgender youth, particularly as reported by supportive families, providers, and advocates. By highlighting these experiences, the report aims to shed light on the human and systemic costs of these policies and to advocate for evidence-based, rights-respecting solutions.

Background

In recent years, the United States has seen a rise in state-level legislation targeting the rights of transgender individuals, particularly transgender youth. Many of these efforts have focused on limiting access to gender-affirming care, a set of often critical social, medical, and psychological interventions that help transgender individuals align their physical bodies with their gender identity.

Historically, such treatments have been supervised by medical professionals and not legislators. Until 2021, no US states had legal restrictions in place limiting such care.

The recent bans come at a time when the United States has experienced an increase in anti-LGBT legislation more broadly. While 2018 saw some 40 anti-LGBT bills introduced in state legislatures, by 2025 this number rose to more than 575 bills.

Gender-Affirming Care for Trans Youth

The rhetoric in these legislative sessions suggests you just walk in and they’re handing you hormones and blockers.... None of that happened. In the first year or more, not one prescription was written. They [doctors] said, “We're here to listen to you and react based off of what you think your needs are.” Which was incredible as a parent, right? It puts you at ease.... It's a slow, methodical process.

— Evan, father of a 17-year-old trans girl in a state with a ban in place, March 22, 2024

Gender-affirming care consists of social and medical practices that treat gender dysphoria and conditions such as anxiety, depression, and suicidality that may arise from the distress of misalignment between one's gender identity and assigned sex at birth. Gender dysphoria refers to a clinically significant distress from the discordance between one’s sex assigned at birth and one’s gender identity (see section I, subsection “Dysphoria” for more detailed testimonies).

Transgender youth are more at risk for mental health conditions, including depression, anxiety, suicidality, and self-harm than their non-transgender peers. Transgender youth were found to have an elevated risk, compared to non-transgender peers, of being diagnosed with depression (50 percent vs. 20 percent); suffering from anxiety (26 percent vs. 10 percent); and engaging in self-harming activities (17 percent vs. 4 percent).[1] Data indicate that 82 percent of transgender individuals have considered killing themselves and 40 percent have attempted suicide, with suicidality highest among youth.[2]

Gender-affirming care for trans youth is a slow, individualized, and iterative process, conducted in accordance with clinical practice guidelines developed by the Endocrine Society[3] and the World Professional Association for Transgender Health (WPATH).[4] These guidelines are supported by the American Medical Association,[5] the American Academy of Pediatrics,[6] the American Psychological Association,[7] and the American Academy of Child and Adolescent Psychiatry.[8]

These guidelines call for gender-affirming care to be offered through a multidisciplinary practice composed of a team of mental and physical healthcare professionals including therapists, pediatricians, pediatric endocrinologists, and other specialists as needed. Parents and guardians are nearly always included in this process. Social workers, trans-inclusive faith leaders, and other social support professionals may be called on to assist in this consultative process.

Gender-affirming care often starts with a social transition, a non-medical process involving changes such as adopting a new name, using different pronouns, changing clothing styles, and altering hairstyles. This initial step allows transgender youth to explore their gender identity and expression before considering any medical interventions.

In accordance with the standard guidelines, youth, after undergoing a period of mental health counseling and receiving referrals from both a mental health professional and a general practitioner or pediatrician, may see a specialist to begin the process of medically assisted transition. Medical interventions are not to be pursued prior to the onset of puberty. For older patients who wish to medically transition, treatment may include hormone therapies.

Puberty blockers and menstrual suppression medication may be offered by doctors as a component of gender-affirming care early in puberty—in consultation with the child, their parents, and their other medical providers—in order stop the body from going through the unwanted physical and developmental changes of puberty.[9] The effects of puberty blockers and menstrual suppression medications are reversible,[10] and are used to give youth time to continue exploring their gender identity before potentially moving on to more permanent transition-related care when they are older.[11] Recent studies have found that puberty blockers can improve mental health outcomes for transgender youth compared to those who were unable to access desired treatment.[12]

Menstrual suppression, achieved through various medications like hormonal birth control, can be offered as part of gender-affirming care for youth to reduce gender dysphoria in patients who find menstruation distressing.[13] These treatments are reversible.[14]

Hormone replacement therapies are generally considered safe in both youth and adults with provider supervision and appropriate management.[15] Depending how long a person has been taking hormones, the effects may be fully or partially reversible as well.[16] The informed consent process involves discussions about side effects and benefits—as with any informed consent process for medication or treatments—including discussions about fertility.[17] Major medical associations have issued position statements highlighting the need to discuss infertility risk and fertility preservation options with youth prior to hormonal interventions.[18]

Many of these medical interventions have long been used to treat various pediatric conditions for patients who are cisgender (a person whose gender identity matches their sex assigned at birth). For instance, puberty blockers have been safely used since 1993, when the FDA approved them for treating precocious puberty, [19] a condition in which children begin puberty unusually early.[20] Recent laws restricting gender-affirming care specifically prohibit these medications for treating gender dysphoria while continuing to allow their use for other medical conditions such as precocious puberty.

While proponents of restrictions on gender-affirming care often focus on surgical interventions,[21] gender-affirming surgeries are exceedingly rare among transgender youth. In fact, they are far more common for cisgender youth, who more frequently undergo medical procedures to align their bodies with their sex assigned at birth. A study published in the Journal of the American Medical Association (JAMA) analyzed U.S. medical data from 2019 and found that out of roughly 150 cases of youth under age 18 receiving gender-affirming surgery, 97 percent were chest reduction surgeries for cisgender male youth with gynecomastia (a condition causing the enlargement of mammary tissue in males).[22] The study also found that for teens ages 15 to 17, the rate of undergoing gender-affirming surgery with a transgender-related diagnosis was 2.1 per 100,000.[23]

Most of the youth who receive gender-affirming care continue this care into adulthood, with a continuation rate of approximately 98 percent.[24] This high continuation rate aligns with evidence of its life-affirming impact: studies consistently demonstrate that gender-affirming care has positive impact on mental health,[25] with findings demonstrating that transgender youth who receive gender-affirming care are 60 percent less likely than transgender youth who did not receive care to experience depression and 73 percent less likely to experience suicidality.[26] These figures suggest both the stability of gender identity in youth receiving care and the critical role this care plays in protecting young lives.

The practice of gender-affirming care is inherently personalized, tailored to each patient's unique needs and developmental journey. While medical professionals customize treatment plans through a holistic and iterative process, recent legislative bans have taken a one-size-fits-all approach that fails to account for this necessary individualization.

The medical community acknowledges the complexities of gender-affirming care, including the absence of decades-long evidence on care that has been accessible since the 2010s, the fullest extent of intervention reversibility, and the nuances of diagnosis and informed assent. These evidence limitations are not unique to gender-affirming care, as many areas of medicine operate under similar conditions of uncertainty.[27]

These nuanced clinical considerations are better addressed by healthcare providers working directly with patients and families rather than through broad legislative prohibitions. Leading medical authorities have established comprehensive clinical guidelines for this care. These medical authorities emphasize that treatment decisions should remain in the hands of clinicians, patients, and their families rather than lawmakers.

Recent bans on gender-affirming care exacerbate existing barriers to health care for transgender individuals, especially people of color, low-income individuals, and those in rural areas. These groups are often uninsured due to factors like employment status, language barriers, and immigration-related fears.[28] Without adequate health insurance, gender-affirming medical care becomes unaffordable for many. Rural residents face additional challenges, including a shortage of providers, longer travel times,[29] and limited health coverage access.[30] LGBT individuals often have to travel significant distances to access culturally competent health care.[31] Even prior to recent bans, over 15 percent of LGBT people reported postponing care due to fear of discrimination, and rural residents faced compounded barriers.[32]

Intersex Exceptions

Many state bans on gender-affirming care include intersex exceptions, provisions in the law that allow or even encourage medically unnecessary surgeries children with intersex conditions while restricting or criminalizing similar care for transgender youth.[33] These exceptions are often framed using medicalized terms like “disorders of sex development” (DSD) and are included in laws targeting transgender individuals, creating a legal double standard.[34]

While transgender youth who seek gender-affirming care with the support of medical professionals are denied access to such care under these laws, children with intersex conditions can still be subjected to irreversible surgeries, such as genital alterations, without their consent.[35] These procedures—performed in infancy or early childhood to conform intersex bodies to binary gender expectations— violate human rights by disregarding the child’s autonomy.[36] Such surgeries are frequently painful, carry significant physical and psychological risks, and can have lifelong consequences, including loss of sensation, infertility, and trauma.[37] Many people with intersex conditions report never having wanted these interventions, which they describe as causing lasting harm.[38]

Despite international recognition of these surgeries as human rights violations,[39] state laws continue to provide immunity to doctors who perform them, prioritizing societal expectations over the bodily autonomy and dignity of children with intersex conditions. By allowing medically unnecessary surgeries on children with intersex conditions while banning gender-affirming care for transgender youth, lawmakers are perpetuating harmful practices that undermine both groups’ right to bodily integrity.

Shield Laws

In response to the growing wave of gender-affirming care bans, 16 states have enacted protective "shield" or "refuge" laws to safeguard access to gender-affirming care.[40] These laws are critical as some states attempt to reach across jurisdictional lines to prosecute individuals, families, or healthcare providers for accessing or delivering care. For example, in 2024 Texas Attorney General Ken Paxton has made efforts to obtain medical records from out-of-state providers as part of investigations into gender-affirming care.[41] Shield laws aim to counter such overreach by creating safe havens where transgender individuals, their families, and healthcare providers can access and deliver care without fear of legal repercussions from restrictive states. Shield laws vary in scope and strength across jurisdictions but typically protect against out-of-state civil suits and criminal prosecution when transgender people travel across state lines to receive care.[42] They also often protect healthcare providers who treat patients from states where such care is banned, and in some cases, shield families who support their transgender children in accessing care.

These laws parallel laws passed by states seeking to safeguard abortion care access after the US Supreme Court overturned Roe v. Wade and several states enacted abortion bans and restrictions.[43] This represents a broad pattern of states working to preserve access to essential health care in response to restrictive legislation in neighboring jurisdictions.

Abortion Bans and Restrictions

Legal restrictions on gender-affirming care parallel constraints on reproductive health care. Following the US Supreme Court’s 2022 decision in Dobbs v. Jackson Women's Health Organization, which eliminated the constitutionally protected right to abortion, approximately 22 million women and girls of reproductive age now live in states where abortion access is heavily restricted or effectively impossible.[44] Like gender-affirming care bans, state legislation enacted in the wake of the Dobbs decision enables the criminalization of healthcare providers and creates liability risks for providers, patients, and those who assist them in accessing care. Both types of restrictions have implications for healthcare systems, as medical professionals may avoid practicing in states where they could face criminal prosecution and avoid providing lifesaving care where they remain, leading to deteriorating healthcare access.[45]

Research shows that reproductive care bans have impacted healthcare ecosystems far beyond the specific focus of the bans, and gender-affirming care bans are likely compounding this problem.[46] In states with abortion bans, medical schools have reported declines in residency applications, particularly in obstetrics and gynecology. For example, Texas, which instituted a near blanket ban on abortion in 2022, saw a 10 percent drop in OBGYN residency applications in 2022, followed by a further 6 percent decrease in 2023, while national application numbers increased.[47] This exodus of healthcare professionals particularly affects rural and underserved areas, where access to medical care was already limited.

Growing Anti-Trans Hostility

We are a part of every single part of this country, and we have been during this entire time showing that we are professionals, we are caregivers. We've proved our humanity and it's very clear to us that that's not enough.

— Carol, trans organizer in a state with a ban in place, September 6, 2024

The United States has experienced a rise in hostility toward transgender individuals, operating through three interconnected channels: legislative restrictions, public rhetoric, and violence. An onslaught of state-level legislation working to restrict transgender rights and visibility through laws has emerged across the nation, while well-funded media campaigns have worked to shape public opinion against transgender individuals and their allies.[48] This hostile climate has corresponded with violence against transgender people, particularly affecting those with multiple marginalized identities.[49]

Bias-motivated crimes now represent a growing proportion of all hate crimes, with gender identity-based incidents making up 4 percent of recorded hate crimes in 2023, up from 3 percent in 2022.[50] However, these statistics likely represent only a fraction of actual incidents, as the current system for tracking anti-trans violence remains inadequate. Many jurisdictions either do not track anti-trans hate crimes at all or do not report them to FBI databases, creating significant gaps in national data collection.[51]

In 2024, at least 30 transgender and gender-nonconforming people were killed in the United States.[52] Seventy-five percent of victims were people of color, predominantly Black transgender women, and half were under the age of 35.[53] According to the Williams Institute, transgender individuals are more than four times more likely than cisgender people to be victims of violent crime.[54] This heightened vulnerability is linked to factors such as systemic discrimination, higher rates of poverty and homelessness, and the lack of legal protections in many jurisdictions, which leave transgender individuals disproportionately exposed to violence.[55]

A 2021 Human Rights Watch report found that in three states studied—Florida, Ohio, and Texas—approximately 90 percent of transgender people killed between 2016 and 2021 were people of color. Black transgender women face disproportionately high rates of fatal violence, reflecting the compounded effects of racism, transphobia, and misogyny. The violence is exacerbated by socioeconomic barriers, including discrimination in employment, housing, and healthcare access, which can force individuals into precarity and limit their options for safety. Yet, the true scale of this violence remains unknown due to inconsistent reporting practices, misgendering in police reports and media coverage, and a lack of standardized data collection methods across jurisdictions.[56]
 

I. Disrupted Health Care Due to Bans

Families and youth in states where youth access to gender-affirming care was disrupted or blocked by state bans described the intensity of gender dysphoria, the clinically significant distress many trans people experience when their physical characteristics do not align with their gender identity. Many of these families said that the criminalization or prohibition of gender-affirming care had a negative impact on transgender youth’s well-being.

Dysphoria

Jack, a 16-year-old transmasculine person living in a state with a ban in effect, described dysphoria as: “[When] the inside of you doesn't match your outside... it’s almost like you want to crawl out of your skin. You're so uncomfortable that you don't want to be in your body.”[57]

Riley, a 26-year-old transman, described how his mother came to understand his dysphoria through her own experience with breast cancer treatment:

She had to have the entirety of one breast and then half of the other removed... And she actually came up to me several months after her surgery and she's like, I may not understand exactly how you feel regarding dysphoria, but I think I have some understanding of what it feels like. And she described it as a feeling of intense discomfort that's kind of like a dull ache and how it lingers for a long period of time.[58]

For some, the pain of dysphoria can be severe. Kai, a 14-year-old trans boy in a state with a ban in effect, said:

I've had suicidal ideation almost all of my life. I remember even as a 5-year-old having feelings of worthlessness and [thinking] why am I even alive? And more so to the point of having bad gender dysphoria, I don't even recognize the person I see in the mirror. Why should I even live this life that isn't mine? And with the ramping up of anti-trans legislation… I felt more suicidal.[59]

Many individuals who experience gender dysphoria may socially isolate, avoid mirrors or photographs, or develop disordered eating habits.[60] Even routine functions can become challenging. As Kai explained, “I got a lot of bottom dysphoria from using the bathroom for a really long time.”[61]

Rachel, mother to a 17-year-old trans girl in a state with a ban in effect, stated:

We had to make a whole ritual around the shower. We'd have to do candles and make sure everything was in a calm, good place, music, things like that.... If we travel and there are mirrors in certain places and bathrooms, that's a huge trigger [to be aware of] as well.[62]

Logan, a trans advocate in a state with a ban in effect, offered this perspective:

Imagine you wake up tomorrow and everything about you is the same, your personality, your values, what you like, your hobbies, everything is the same except you're now the opposite sex.... How that would feel and how you'd have to face your family, your friends, your spouse, and try and stand in your conviction that you are who you are.[63]

The onset of puberty often intensifies gender dysphoria for transgender youth as their bodies develop secondary sex characteristics that conflict with their gender identity. This distress can become acute when access to gender-affirming care is interrupted, as is the case for many families impacted by bans on gender-affirming care. Kai, who hasn’t been able to initiate gender-affirming care due to bans in his state, said, “It felt like I wasn't allowed to have puberty and be happy and just be a regular child. I had to feel horrible and depressed and suicidal because it isn't who I am–to be in a woman's body, to be going through a female puberty—because I'm not a girl.”[64]

On the other hand, when transgender individuals receive gender-affirming care and their bodies begin to align with their internal sense of self, many transgender people describe experiencing gender euphoria, a sense of joy and satisfaction that arises when one’s gendered experience aligns with their gender identity rather than their assigned gender at birth.

Grace witnessed this transformation in her 18-year-old son. Before starting gender-affirming care, her son would cry at his own reflection in the mirror, Grace said.[65] She recalled the impact of gender-affirming care: “Shortly after [he started] testosterone, I walked by and he was in the bathroom grinning, grinning at himself [in the mirror] like an idiot. And I'm like, ‘What are you doing?’ And he said, ‘I finally feel like myself.’”[66]

Kara, a gender-affirming care provider in a state with a ban in place, stated:

The transformation is life-affirming…. Patients are so happy and just… it looks like a whole different person is in front of you.[67]

Disrupted Care

Families who traveled out of state to receive care described the significant geographic and financial burdens imposed by bans on gender-affirming care,[68] as well as the toll on mental and physical health. Some families had to fly to access doctors, while others drove long distances. Many parents reported that they had to miss work, and their child had to miss school, to accommodate these trips. The costs added up quickly, and included expenses such as airfare, gas, hotels, lost wages, and complications with insurance coverage.

Two families said that they had to establish care in new states twice, as the first state where they sought treatment later enacted its own ban. Clinics providing gender-affirming care for trans youth often cease offering this care abruptly ahead of a ban’s enactment or “overcomply” with state measures, halting legally permitted services or referrals out of fear of prosecution or other repercussions.[69]

Deteriorating Mental Health

According to a 2024 study by the Centers for Disease Control and Prevention (CDC), an estimated 875,000 high school students in the United States identify as transgender or are questioning their gender identity.[70] Approximately 26 percent of transgender students reported attempting suicide in the past year, compared with 11 percent of cisgender female students and 5 percent of cisgender male students. For suicide attempts resulting in hospitalization, the disparities are similar: 10.3 percent of transgender youth required medical treatment, compared with 2.5 percent of cisgender girls and just 1 percent of cisgender boys. This translates to tens of thousands of transgender youth requiring emergency medical care for suicide attempts in 2023 alone.[71] These figures arise as US youth are reporting high rates of depression, anxiety, and suicidal ideation more broadly;[72] however, transgender youth remain at significantly higher risk.

The introduction of anti-trans legislation can exacerbate mental health struggles by fostering an environment of hostility. Recent examples highlight the nature of legislative debates: an Oklahoma lawmaker referred to transgender people as “filth”;[73] a Florida legislator used the terms “demons” and “mutants.”[74]

Transgender youth interviewed for this report described the devastating effect bans on gender-affirming care have had on their mental health. Of the families Human Rights Watch interviewed, parents or youth attested to seven accounts of attempted suicide or suicidal ideation related to transphobia, and in some cases, directly correlated to the passage or threat of a ban on gender-affirming care. Three attempts resulted in hospitalization. Even in cases where the affected youth had not lost access to care, the hostile cultural and legal environment took a severe emotional toll.

Sarah, the mother of a 17-year-old trans girl living in a state with a ban on gender-affirming care, described how she had secured care for her daughter, Mylie, years before the law was introduced. After nine months of counseling and evaluation by a pediatric psychologist, Mylie began seeing a pediatric endocrinologist in her family’s hometown in 2019 when she was 12 years old.[75]

Over the course of four years, her physician adjusted her treatment to match her development, allowing her to mature alongside other girls in her grade. Both Sarah and Mylie said that puberty blockers and hormone therapy helped alleviate Mylie's dysphoria by preventing male puberty and allowing her to develop into the young woman she is today. This care enabled her to live a fuller, more open life, Mylie said.[76]

Before her social and medical transition, Mylie faced bullying for her appearance, including her long hair, particularly when using the men's bathroom. Feeling unsafe in either restroom, she would restrict water intake throughout the school day, a behavior that may have contributed to her development of kidney stones. Following her social and medical transition, Mylie gained the confidence to use the women's bathroom with the support of her school and no longer experienced kidney issues.

As Sarah recounted:

For her to come out as a young child and have that kind of atmosphere where she'd be supported, she was given the opportunity to have the blockers so her body did not go further into a transition into a body that she does not identify with… her voice never dropped… and [she was] able to go to the bathroom and own it. This is my bathroom. I'm a girl. All those things immediately reduced the anxiety.[77]

Mylie added, “It was much more enjoyable to be in school. I didn't have to worry about my gender identity or what I presented as. I just had to worry about school at that time.”[78]

The family’s life changed when their home state passed a ban on gender-affirming care which included an “aiding and abetting” clause penalizing physicians who facilitated care. Without notification, the pediatric endocrinologist they had been seeing throughout Mylie’s adolescence abruptly ceased offering gender-affirming services when the law was passed, but before it took effect. Mylie recounted that the doctor “completely vanished off the face of this planet for three weeks and no one knew where he went.”[79]

After weeks of silence, their doctor resurfaced but did not offer referrals or sent medical records. As Sarah recalled:

He was not willing to refer anybody to the doctor [in a nearby state without a ban] because he was told that would be considered facilitating care. So, what he would do is he would write on a piece of paper the name of the doctor and slide it across, not say anything out loud, just slide it across, and it was up to the patient to decide what they did with that. When he felt that became too risky, he started to write the name of [a local LGBT center] on this paper and slid it across, and then it became on [that organization] to get them referred to the physician in [a nearby state without a ban] so that there would be no further facilitation of care.[80]

Before the law went into effect, the doctor stopped treating trans youth. He additionally stopped sharing records, such as blood test results, with other clinics. The situation worsened after the law took effect, as his office refused to transfer patient records to “any endocrinologist anywhere in the United States” because he viewed this as “facilitating care.” Sarah recalled that as a result, “many trans [youth] who traveled out of state or who moved, had to start all from scratch with a brand new endocrinologist” because they couldn't access their previous medical records.[81]

The ban on gender-affirming care, as well as other state laws targeting trans youth, caused Mylie’s mental health to decline. As she recalled:

The fear of losing the thing that's making you yourself and that's allowing you to express yourself to the community is a very scary feeling. And my mental health had severely dropped during that time. I was constantly worrying about if I had to move away or just leave everything behind in the fear that this law would pass. I had become less social. I had not been doing my schoolwork. I didn't want to go out of my room. I didn't eat as much, I didn't do it. It was basically a loss of everything, motivation.... It had been making me fear that I've only had so much time left to show my true self before it was completely taken away.[82]

In response to the state ban on gender-affirming care, Mylie attempted suicide twice. As her mother, Sarah, explained, “there were times of me having to sit in the hallway of her bedroom, not wanting to leave her alone, like her being on the bathroom floor and crying. This is stuff that we never had before.”[83]

Mylie was eventually able to establish care with a physician in a neighboring state who provided gender-affirming treatment. Sarah travels to the same neighboring state to pick up Mylie’s prescriptions. Whereas before the ban the family’s insurance was able to process the medications, now the medications must be paid for out of pocket. If submitted through insurance, the claim is automatically rejected based on their family’s zip code given the state law.

Rachel, the mother of 18-year-old Sophia, described how her state's gender-affirming care ban disrupted her child’s treatment and harmed both her mental and physical health. Before the ban, Sophia began care at a gender clinic in their hometown. The staff was understanding, and the care began gradually.[84] The doctors monitored Sophia closely, and she began hormone therapy at a low dose. Sophia showed signs of improvement in the first few months—she was happier and more comfortable in her skin. However, when the ban passed, the clinic stopped her treatment. Though her physician assured Sophia and her mother they could quickly secure an appointment in a neighboring state without a ban, the overwhelming demand left the earliest available appointment five months away.

As anti-trans rhetoric escalated alongside the ban, Sophia's mental health plummeted, Rachel said. She withdrew from school and began self-harming. Concerned friends confided in a school counselor, who contacted Rachel. In the middle of her workday, Rachel received a call informing her that Sophia had a suicide plan. Rachel rushed home, fearing what she might find. She and her husband immediately took Sophia to the hospital, where she was admitted for a week.

Rachel told Human Rights Watch that she believed the anti-trans legislative and rhetorical climate triggered Sophia’s mental health crisis:

It was just the message that if you're trans… that's a lie and you need to go to church and you don't need that medicine.... And I just can remember hearing that message over and over, and I would turn the TV off or whatever, but I just remember one day having a really bad day, and we were going through a lot of emotions, and I just wanted to break my television. I mean, I was just like, what in the hell?... So yeah, the politicians really… for lack of a better word, infuriate me.[85]

When Sophia was hospitalized in her home state, the medical staff, citing the state’s ban, refused to administer her hormone regimen even though it had been prescribed before the ban took effect. Desperate, Rachel attempted to sneak the medication in during her visits but was thwarted by security measures. Rachel also tried to transfer Sophia to a hospital in a state without a ban, but long wait times and Sophia’s vulnerable state made it impossible. As a result, Sophia missed 14 doses of her hormone treatment during her hospitalization. Sophia reported heightened anxiety during this time, questioning how she could improve while being denied the medication she needed.

To complicate matters, Sophia’s hospitalization coincided with a long-awaited appointment at a gender clinic in a neighboring state. Unable to reschedule in a timely manner, Rachel scrambled to find alternatives for her daughter's care. Eventually, she secured an appointment at another clinic, but Sophia’s prescription would run out before the appointment date. Rachel found someone online in her hometown who provided the necessary medication to bridge the gap until Sophia could receive proper care at the clinic.

It's crazy—I felt like I was trying to get illicit drugs. This really sweet trans woman reached out and said, “Please don't tell anyone, but I have this.” I checked with my doctor, and he confirmed it was safe. It was sad because she [the woman she met online] was so scared I might turn her in. I remember when I met her to get the meds, we hugged. She’s in her late forties, transitioned later in life, and shared how she never had a loving, accepting parent.[86]

Sophia eventually established care at a new gender clinic six hours away, and the family had to make two trips before she turned eighteen. Each visit required Sophia to miss a full day of school while Rachel had to take time off work without pay. Although the care was not covered by insurance, both the clinic and a pharmacy nearby worked with the family to reduce the financial strain. Now 18, Sophia receives gender-affirming care in her hometown. Reflecting on the ordeal, she remarked, “I want [lawmakers] to know they’re ruining people’s lives.”[87]

High Costs and Protracted Procedures

The implementation of gender-affirming care bans has forced many families into complex, expensive arrangements to maintain their children's access to essential health care. Parents are having to navigate a maze of out-of-state providers, long-distance travel, and mounting costs, turning routine medical care into logistically challenging expeditions. Beyond the immediate financial strain, the protracted nature of these arrangements creates additional challenges for children's education, parents' work schedules, and the consistent delivery of medical care. These burdens fall particularly hard on families who may lack the financial resources or flexibility to make regular interstate trips for health care and may have to forego such care entirely as a result.

Evan, the father of a 17-year-old trans girl in state with a ban in place, discussed the difficulties of maintaining access to his child's hormone prescriptions as refills run out later this year. Their current strategy involves traveling four hours to a pharmacy two states away. “It’s a whole day out of your week,” he said. He noted that “a lot of families don’t have that opportunity... they can't just pick up and go to [that state] because of work, school, or money.”

Other families have taken to routinely flying out of state to ensure their child’s access to gender-affirming care.

Lucas, the father of a 13-year-old transmasculine adolescent, told Human Rights Watch that before his state’s ban his child, Paul, was able to receive care from a local children’s hospital which had a long-standing multidisciplinary gender clinic.[88] However, when legislation targeting youth access to gender-affirming care began surfacing in his home state, the hospital preemptively shut down its gender clinic. This decision was driven by fear of the vaguely worded law restricting this care. Although the law was challenged in court, the legislative atmosphere discouraged institutions from offering gender-affirming care.

As a result, the family had to seek care outside the state, with Paul now flying every six months to receive care from a physician in a state without a ban in place. Lucas estimates each visit costs the family over US$2,000 in travel expenses alone.

Amelia, the parent of a 10-year-old trans girl, Natalia, described the challenges her family faced while seeking gender-affirming care in their home state. Although Natalia was not yet ready for medical interventions, her mother felt it was vital for the family to establish a relationship with a provider who could monitor her development as she approached puberty. Amelia found a gender clinic in-state, but after their first consultation, the clinic abruptly shut down following the passage of a state ban on gender-affirming care, even though the law had not yet taken effect. “I tried to call them, but nobody answered, and we realized they had shut down,” Amelia recalled.[89]

With no local options remaining, Amelia and her family expanded their search nationwide. Many providers in states without such bans refused to see out-of-state patients, limiting their options. After extensive searching, they found a clinic in another region, but accessing it required air travel. Each trip costs the family approximately $800-$900 in travel expenses alone. They have been able to stay with a relative who lives near the clinic, avoiding lodging costs. But the travel expenses are high enough that they cannot visit as often as they and their provider would want to be able to consistently monitor Natalia's development. As she grows older, more frequent appointments will be needed, increasing the financial and logistical strain on the family.

Amelia is concerned about the impact of limited access to care on Natalia's well-being:

I can't imagine forcing my child to go through development as a man and then have to reverse it later. To her, it would be agony. I mean, she's so nervous that she's going to get facial hair. She's like, “I really just don't want to have facial hair. When is that going to happen? I don't want to look like a boy.” And just the thought of making her go through that really is very distressing for her, as distressing as it is for me when there is a treatment out there that could help her develop the way that she wants to be seen, in the way that she feels inside. So I hope that we'll be able to access the treatment that she needs if that's what she chooses.[90]

Natalia added, “It's like they [lawmakers] are socially executing us from society.”[91]

For other families, the delays and gaps in care caused by these bans have had devastating effects, particularly for youth on the brink of puberty. Unwanted secondary sex characteristics, such as changes in voice, breast tissue density, and body hair distribution, can be prevented with timely access to puberty blockers.[92] Without this intervention, these changes are harder to reverse and may require more costly, invasive, riskier, or painful treatments later on (such as surgery, laser hair removal, or voice therapy). The inability to access care at a pivotal time can lead to physical developments that compound the emotional and medical challenges for transgender youth, increasing the need for more complex and costly interventions down the road.

Hannah’s 10-year-old trans daughter, Lily, was approaching puberty as their state legislature passed several anti-trans laws, including a care ban. The family relocated across the country to a state without a ban in place to ensure their daughter could access age-appropriate medical care and grow up in a supportive environment.

Hannah described the decision to move: “That was really hard for us. My husband had lived there his whole life.... His mom is getting older, and she had moved closer to us specifically so we could help her. And so there was a lot of anxiety about what is going to happen with her, who's going to help her.”[93]

She added: “We had been involved in that community for over 20 years… and had put a lot of work into making it our space and put a lot of work into having a community for our family.”[94] They chose not to tell Lily the real reason for their move, not wanting to burden her with that responsibility. “It was hard to explain why we had to leave while omitting that, which was pretty much the reason we were leaving.... From her perspective, [there was] no good reason.”[95]

Hannah and her husband had found acceptance for Lily, who was clear about her gender identity from an early age, as young as four when she first asked to her parents to start calling her Lily.[96] In those early years, their local community showed support for their family, but the political climate recently shifted. The passage of restrictive legislation around LGBT rights in schools not only created confusion but also emboldened hostility toward LGBT people and their families.

The healthcare restrictions, however, became the decisive factor in their decision to leave. While Lily was still too young to begin medically facilitated gender-affirming care, her parents had proactively established care with a local youth gender clinic to ensure she had appropriate medical support as she approached puberty. But as state authorities began discussing bans on gender-affirming care, their daughter’s medical providers expressed alarm: “We don't know if we can continue to serve you. We don't know what this means for us or for you or how this works. We don't have anyone to refer you to.”[97] The situation was further complicated by Hannah and her husband's positions as state employees, which meant their insurance coverage for gender-affirming care hung in the balance.

The state's new restrictions offered limited protection through a grandfather clause for youth already receiving hormone treatment, but this provided no help for Lily, who hadn't yet started such care. As Hannah explained: “They were grandfathering people in. If you were already receiving any kind of hormone treatment, then you could continue to receive it for the time being, but since she hadn't started yet, she wouldn't be allowed to access it.”[98]

Hannah added: “We felt like we were in this window where she would need to start on it as soon as she hit puberty and we didn't really feel like we had the time for the government and the courts to sort all of that out.”[99]

Barriers Due to Insurance

Families coming from states with bans who successfully located out-of-state providers faced significant financial obstacles to accessing gender-affirming care. Insurance coverage often becomes an obstacle, with some insurers withdrawing coverage once families sought care across state lines.

Ethan, an LGBT healthcare advocate working in a state with a ban in place, highlighted an insurance coverage disparity: while puberty blockers are routinely covered for conditions like precocious puberty,[100] insurers often deny coverage when the same medications are prescribed to treat gender dysphoria. He said:

It's hard to overstate the impact of not being able to access the care you need, not only because there's a difference between the care being banned and coverage being banned. For some of these folks, the fact that they are allowed to get it, they just can’t pay for it, is so demeaning and demoralizing and knowing that if the diagnosis code were anything else, anything other than gender dysphoria, it would be covered. And they would be afforded the same exact medical necessity analysis as everyone else, but solely because they're transgender, solely because the diagnosis is gender dysphoria, it’s categorically excluded.[101]

Ethan said that out-of-state care presents additional insurance hurdles: “When people go out of state, their chances of coverage plummet. Their best hope is securing a network gap exception, which insurers rarely grant for gender-affirming care. This makes accessing necessary treatment virtually impossible.”[102]

Janet, the mother of a 15-year-old transgender boy living in a state with a ban in effect, experienced these challenges. Although her family managed to locate an out-of-state provider, her insurance company denied coverage for her son's medications due to the gender dysphoria diagnosis.[103] The out-of-pocket cost was $4,500 every six months. While Janet secured a partial coverage solution through advocacy with her insurance company and healthcare provider, the medication still costs $600. These financial barriers and administrative delays prevented her son from receiving a scheduled dose of puberty blockers, triggering the restart of puberty:

He started developing again his breasts and that was upsetting.... [It] was mentally taxing on him seeing those physical changes because the puberty blocker paused [them]. And seeing those changes happen again, it was really upsetting to him. He's like, “Mom, my breasts started growing. Mom, I started my period again.” I know that did not help his mental health.[104]

The financial burden is more severe for low-income families, particularly those relying on Medicaid. Currently, twelve states prohibit Medicaid coverage for transgender youth seeking gender-affirming care, and ten of these states extend this exclusion to all transgender people regardless of age. Maya, a civil rights attorney, has witnessed the impact of these Medicaid restrictions: after her state banned coverage for gender-affirming care, she observed families of transgender youth without insurance coverage being quoted up to $26,000 every three months for puberty blockers.[105]

Inability to Initiate Gender-Affirming Care

Human Rights Watch documented three instances in which youth were unable to initiate gender-affirming care due to legal bans on this care as well as financial and geographic constraints.

Taylor struggled for years to secure gender-affirming care for her 14-year-old transgender son, Kai. At age 12, Kai began showing signs that he needed mental health support. Taylor recalled: “[On] the last day of school, he specifically tells me that he's feeling suicidal.... I keep him home and that's when we set up the initial evaluation [with a mental health counselor].... It's like that was just a band aid for a gushing wound.”[106]

Despite this urgent intervention, finding a therapist who could continue seeing Kai proved challenging, as there were very few providers competent in transgender care for youth. It took nearly a year before they could secure consistent mental health support. Then, their home state enacted a ban on gender-affirming care. The family had hoped to be “grandfathered” in under the law’s provision, which allowed youth already receiving care to continue. They believed they had established care when their supportive primary care provider referred them to a gender clinic, and an appointment was scheduled for the earliest available date. Taylor recalled the moment the clinic called to delay the appointment two months because the doctor was unavailable: “I started crying on the phone. I know how important this is, I know it is urgent, and I know what's at stake. And she [the clinic staff member] was like, ‘I’m going to have to hang up the phone now.’”[107]

Although the clinic later reached out to schedule a one-on-one consultation to better understand the family’s needs, they faced another setback: Kai needed a referral to a clinic in a neighboring state without a ban, prolonging the wait. “There have been several times where I have panic attacks, and I worry that I'm not going to even make it to next year because I honestly can't live,” Kai said.[108]

The state’s ban had impeded the possibility of timely medical intervention, leaving the family with difficult decisions. They chose not to pursue care in another state, as the family is relocating to a foreign country for the father’s job, a decision which was influenced, in part, by the lack of gender-affirming care available in the US.

Legislative bans have exacerbated the impact of pre-existing barriers to initiating gender-affirming care, such as financial constraints, geographic limitations, and insurance challenges.

At 14, Sasha came out as transmasculine and began to socially transition. While this eased their social interactions, they still grapple with dysphoria, especially around their chest, height, and voice. A performer, Sasha avoids watching recordings of themself due to discomfort with their appearance. Though Sasha and their family live in a community where hostility toward LGBT people is common, Sasha describes their parents as supportive.

Sasha has long wanted to pursue gender-affirming care, but a state ban has made it inaccessible. While some youth seek care out of state, this option is not feasible for Sasha’s family, who live in a rural area far from clinics and lack the financial resources for travel, mental health counseling, and the healthcare costs associated with gender-affirming care. Sasha said, “I love [my state] just as a state and as a culture, but just the knowledge that it's not in my best interest to live here—I don't know, it feels a little jarring.”[109]

Eli, the father of an 11-year-old trans daughter, described the challenges his family faces due to their state’s ban on gender-affirming care, and how these challenges are compounded by financial obstacles. From a young age, Eli’s daughter was clear about her identity. He recalled a moment when she drew a picture of herself as a girl, “She was just so happy, smiling ear to ear in a little red dress, her favorite color. It made me cry seeing her so free in who she was.”[110]

The legislative ban has derailed the family’s efforts to talk through options with a doctor and access the care Eli’s daughter wants. They had an appointment lined up to discuss the administration of puberty blockers, but it was canceled due to new restrictions. “We were so close, we had an appointment. But with the ban, it's all gone. It’s like, do I uproot my family just so my daughter can get the care she needs?”[111] While Eli is determined to fight for his daughter’s right to care, the financial and logistical hurdles make out-of-state treatment unattainable. Eli expressed concern about the future, as his daughter is approaching puberty. “Right now, she looks very androgynous. They take her as a cis little girl, but as she grows older, I’m worried more about that.”[112]

LGBT advocates describe seeing similar struggles across their communities. Chloe, an organizer in a state with a ban, observed that some youth choose to endure severe dysphoria rather than burden their parents:

Kids are extremely resilient, and they look at the stress that their parents are under. And a kid who is suffering with gender dysphoria might go, “I don't want to be this burden to my parents.” And they might self-select not getting hormone therapy or not getting puberty blockers and live through that misery because they don't want to put additional stress in their family for having to go out and get that care.

Leo, an LGBT organizer working in another state with a ban in place, emphasized how these bans particularly impact low-income families: “There's essentially nothing they can do unless they want to move out of state. A lot of folks just don't have the time and the money to make those long commutes to access that gender affirming care.”[113]

State bans on gender-affirming care for transgender youth have created a complex web of barriers that leave transgender youth and their families struggling to maintain essential medical care. The impacts range from severe mental health crises to high financial burdens, with some families unable to access care altogether. These policies have effectively forced families to choose between their home communities and their children's well-being, with particularly severe consequences for those without the resources to seek care across state lines.

II. Impact of Bans on Gender-Affirming Health Care on Healthcare Providers and Facilities

Gender-Affirming Health Care: Practices Before the Bans

In interviews conducted after the bans were enacted, healthcare providers said their previous practices had been holistic and tailored to each patient's needs. They emphasized the importance of working in multidisciplinary teams that often included pediatric subspecialists, mental health professionals, and social workers. This collaborative approach ensured that care was both medically appropriate and supportive of the patient's overall well-being, addressing not just physical health but also social and emotional needs.

Providers highlighted that treatment decisions were made through ongoing discussions with patients and their families, ensuring that the care provided aligned with the individual’s evolving experiences. This patient-centered approach fostered an affirming environment where youth could safely explore and express their identities, ultimately promoting positive outcomes in self-esteem, social integration, and mental resilience.

Olivia, a provider in a state with a ban, reflected on the pediatric gender-affirming care that existed before the ban:

Prior to 2021... there were probably 50 plus of these very similar multidisciplinary teams in pediatric academic centers around the country... bringing together expertise in primary care, adolescent pediatric health, pediatric endocrinology, child and adolescent psychology.[114]

In addition to medical specialists, these clinics included a range of supportive services: chaplains, social workers assisting trans clients with public services, lawyers helping with name and gender marker changes, dietitians, and speech therapists. Olivia emphasized the role chaplains played:

I felt it was critically important to invite pastoral care... and to my surprise, they jumped at the opportunity.... Our chaplain works closely with families, less so with the kids. Our young people don’t find faith to be a challenge, but parents often struggle.... We've had parents fired from their jobs for affirming their child.... Our chaplains help interpret scripture around love, affirmation, and life.[115]

Ethan, the father of a 17-year-old trans girl, described the care his child received at Olivia’s clinic:

You hear these bills talk about handing out hormones... but none of that happened in the first year or more.... The doctors were there to support [my daughter], with no pressure. Mental health professionals spent time talking to her, asking about school, her friends.... It means a lot to us as parents.[116]

Colin, a gender-affirming care provider, described his clinic, which served trans youth up to age 24 before his state’s ban on that care went into effect. The clinic provided comprehensive care through an interdisciplinary team, including a full-time psychologist and social worker, multiple medical fellows, and a faculty physician who dedicated part of their practice to gender care. The clinic maintained an affiliated eating disorders program specifically serving gender-diverse patients, while working closely with community organizations that provided a range of services. These included mental health support and practical assistance such as legal help for documentation changes and binder fitting services.[117] The community partnerships also offered support for young adults, including job training programs and housing assistance, with specific resources available for those navigating life after experiencing incarceration.[118]

Olivia explained how clinics are often consulted in crisis situations:

When you work with adolescents, they’re not separate from their families and communities.... We consult on youth in inpatient settings, emergency rooms, and psych units—those who have harmed themselves due to dysphoria and household conflict. Often, these interventions are an eye-opener for parents, and we serve as a crucial bridge. We’re fortunate to follow some of these kids in the clinic afterward, and you can see light emerge from very dark places.[119]

She emphasized that, during moments of crisis, the ability to work collaboratively with both the child and their family can be transformative. This ongoing support, she noted, allows for healing.[120]

Colin also spoke on the impact of gender-affirming care on his patients:

This is one of the few clinical spaces you'll ever work in, where most days on many visits, that encounter will just make you happy because you will leave it feeling like something good has happened. The kids will tell you that. They'll show you that they will express the degree of relief, a sense of being normal for themselves. They're proud of themselves.[121]

Gender-Affirming Health Care: Practices After the Bans

States with Bans in Place

Providers, parents, youth, and LGBT organizers who spoke with Human Rights Watch described bans on gender-affirming care as “profoundly disruptive,” marked by vague language that fueled confusion and uncertainty. Legal battles frequently paused and then reinstated these bans without warning, creating a chilling effect that forced clinics to either turn away patients or limit their services even before bans were upheld or struck down by courts.

The inclusion of “aiding and abetting” clauses have made providers hesitant to inquire about patients’ medical regimens after a ban is in place, restricting their ability to share crucial information or make appropriate referrals.

Additionally, legal provisions that classify the provision of gender-affirming care as a felony offense, meaning possible criminal penalties for noncompliance, have intensified healthcare providers' fears and reduced their willingness to deliver such care. As a result, many providers have adopted more restrictions than strictly required under these bans, aiming to avoid potential legal repercussions.[122]

Human Rights Watch spoke with five gender-affirming care providers in four states with bans in place who all had to halt their practice or specific services as a result of legislative bans.

Molly, a gender-affirming care provider, said that her clinic struggled after a ban on youth care was passed in her state, but due to litigation, did not immediately take effect. Molly said the law left her team asking, “What can we do to support families? How will we adapt if this law does go into effect?”[123] The temporary pause in the law’s enactment provided little relief, as providers faced stress over potential changes. When the law suddenly took effect, Molly said, “Overnight, no medical care could be provided for minors.” Molly’s clinic was forced to quickly reassess how to continue supporting families in a restricted environment, she added.

In Molly’s state, the ban includes an “aiding and abetting” provision that caused further complications, leaving providers uncertain about what was legally permissible. Describing the “aiding and abetting” provision as “the part that has been most confusing” about the new state law, Molly asked:

What can we say is giving information to your family? The way the law is written is … you can't aid and abet… the provision of [a] “gender transition procedure.”

That's the language of the bill, which is also a strange way of describing hormone therapy and puberty blockers.[124]

Molly said that she also experienced challenges with local pharmacists, who, fearing liability under the state’s aiding and abetting clause, were reluctant to dispense medication that may be seen as the provision of pediatric gender-affirming care. Treatments for unrelated issues, such as menstrual suppressants, were sometimes taken by pharmacies as gender “transition procedures,” necessitating additional communication from healthcare providers. “We have to provide pharmacists with more information than they're entitled to,” Molly said.[125]

At another clinic, Colin, a pediatric gender-affirming care provider, said “The trauma associated with the disruption of care was very acute,” Colin explained, even among the many patients who had already braced for the possibility of losing access.[126] “Many saw it as a signal that the environment had become hostile,” he added. For patients over 18, the clinic continued providing hormone therapy, but younger patients were forced off treatment. “We had several hundred people... come off hormones,” Colin recounted. “In the first month, we discontinued 60 [patients], and we've continued to proceed at about that pace since then.”[127] At the time of the interview with Human Rights Watch, Colin estimated that he had ceased hormone replacement therapy for over 300 youth patients. The clinic also avoided discussing patients’ remaining hormone supplies in order to stay within the bounds of the law, which had an aiding and abetting clause.

Overcompliance with State Laws

The vagueness of these laws led clinics and providers to cease more services than likely legally required out of fear of legal repercussions. Individuals reported that providers, pharmacists, and lab technicians used youth care bans as justification for ceasing referrals and medical services that were not explicitly prohibited by these laws.

Chloe, an LGBT organizer in a state with a gender-affirming care ban that includes criminal penalties, said that uncertainty has led doctors to stop providing all gender-affirming services, even though the law's “grandfather provision” allows youth already receiving puberty blockers or hormone therapies to continue. However, the provision is considered too vague by many providers and hospital administrators, causing many doctors to avoid potential legal risks.[128]

Tessa, an LGBT organizer in a different state, said, “When these medical clinics take these laws to their lawyers, the lawyers will advise them basically to err on the side of caution,” she said.[129] The ambiguity, she explained, creates a “de facto limit” that restricts care, while lawmakers remain “not very forthcoming” with clarifications.[130]

Jack, a 16-year-old transmasculine person who had been working with a gender-affirming mental health provider for over two years and had support from his parents, encountered resistance when seeking a referral for care. His pediatrician—who was unsupportive of his transgender identity—refused to refer him to an out-of-state gender-affirming care provider, citing Jack’s state’s ban even though the ban did not include an aiding and abetting clause that would make referrals illegal.[131] “One of the doctors called my mom and said, ‘I’m sorry about the timing. We can't do the [referral] letter because the law is against it,’” Jack recalled.[132]

Doctors are not the only professionals grappling with these laws: lab technicians and pharmacists are also confused, often opting to restrict care to avoid any possible legal repercussions.

Ethan, a healthcare advocate in a state with a ban in place, said lab orders sent from out-of-state facilities faced issues when labs in his state refused to process blood work related to gender-affirming care. “Even if they get the lab order sent to a lab in [my state], local labs sometimes think they can't do the blood work because it's around gender-affirming care,” Ethan explained.[133] Similar confusion affected pharmacies, where some pharmacists believed they couldn’t dispense medications even if they were working in states whose laws did not specifically cover pharmacies.[134] Individuals on hormone replacement therapy (HRT) had to travel to pharmacies in other states, adding to the burden of care: “If they’re on HRT... they would have to go to a pharmacy in a different state where there's no ban,” Ethan said.

This pattern of overcompliance extends into mental health care settings as well. Shauna, a psychiatrist at an inpatient facility in a state that has banned gender-affirming care, witnessed her hospital implement restrictive unofficial policies—restrictions the hospital imposed on itself in the wake of the ban, based on its cautious interpretation of the new law—which limited providers’ ability to affirm the experiences of trans youth.[135] The hospital strongly enforced these unofficial measures at the same time that it was seeing an increasing number of trans patients seeking mental health care.

When she started working at the hospital in 2020, Shauna saw very few trans patients, but by late 2023 reported that many more youth were coming forward for care.[136] These were young people in acute crisis, with most admitted following suicide attempts or severe self-harm, requiring urgent psychiatric care. Despite the vulnerability of this population, the hospital maintained highly restrictive policies around addressing gender identity.

Even though the state law had no explicit legal prohibition on affirming language, staff at her facility were told not to acknowledge transgender patients’ difficult home situations or provide basic resources without parental permission. Affirming language in this context meant routine statements that reflected what a patient had expressed, such as validating their emotions or naming the challenges they face. “We can't say, ‘I know your gender dysphoria is difficult, but there's all these other resources’ because we have to have permission from the parents to even talk about that [dysphoria] with the child,” Shauna explained.[137] The consequences for failing to follow these policies were potentially severe; she had witnessed a non-binary staff member face disciplinary action simply for acknowledging a trans patient’s unsupportive home situation.

Stockpiling and Prescription Access

Two providers in states with bans that include aiding and abetting clauses said that one consequence of these provisions is that they are unable to offer guidance, oversee treatment, or conduct routine lab tests for patients who are still using hormones.

Molly explained that many patients had “stockpiled medication, expecting something to happen,” and are now using those supplies without medical oversight.[138] “They can't discuss dosing with medical providers because the providers can’t help manage that,” she said.[139] Unsupervised use of hormone replacement therapies may pose risks, including incorrect dosing, which can lead to health complications.[140] Without professional guidance, individuals may also lack monitoring for side effects, increasing the likelihood of harm and undermining the effectiveness of their treatment.

States Without Bans in Place

Human Rights Watch spoke with two providers in states without bans on youth access to gender-affirming care who serve patients from states where bans are present.

Renee, a gender-affirming care provider in a state without a ban in place, remarked, “I knew [legislative bans] became a problem when parents from states with emerging bans reached out to me to ask for a connection to clinical services in my home state.” Renee has facilitated care for five transgender youth from out of state, noting that the most well-resourced youth and their families are the ones able to go to extraordinary lengths to secure essential care.

Renee said that “being able to develop a relationship with a provider” is vital for adolescents. Continuity of care fosters connections over time, enabling patients to disclose sensitive issues as they mature. She stressed that in moments of vulnerability—common in gender-affirming care—maintaining a consistent provider is crucial. Disruptions in care, such as those frequently caused by legislative bans, can lead to substandard treatment outcomes.[141]

Daniel, a gender-affirming care provider in a state without a ban in place, discussed the establishment of a youth program at his clinic in response to the growing need for gender-affirming care among transgender youth. The program was initiated out of necessity, as demand rose as other states enacted bans, leading to waitlists at clinics that could provide this care. Daniel explained, “There’s not enough slots for youth that need it.... Nobody would do this [start a new clinic program] if there wasn’t a need there.”[142]

Daniel reported that while some patients travel long distances for their appointments, most are relocating to his state for ongoing care. He emphasized that the increase in demand for services is directly linked to legislative restrictions in other states: “The needs definitely come from the bans.”[143]

Harassment and Targeting of Healthcare Providers and Facilities

Gender-affirming care providers and facilities have come under attack as legislative bans and anti-trans hostility create a climate that is ripe for violence. This environment normalizes harassment and intimidation, increasing their likelihood.

States began banning gender-affirming care in 2021, which drew increased media attention to the issue. In 2022, the Human Rights Campaign released a report documenting online attacks against 24 hospitals across 21 states, spurred by inflammatory and misleading posts from conservative social media accounts.[144] These online campaigns had real-world consequences, as doctors and hospitals singled out on social media faced harassment and threats at their homes and workplaces. In the most extreme cases, doctors received death threats, and hospitals were subjected to bomb threats, causing temporary disruptions in care for all patients.

A 2022 study surveying 117 gender-affirming care providers found that 70 percent had received threats specifically related to their work.[145] Providers described the mental and emotional toll of these threats, with many reporting anxiety. Some reconsidered whether to continue offering gender-affirming care.

Every gender-affirming care provider interviewed by Human Rights Watch reported experiencing some form of anti-trans harassment—whether directed at themselves or their place of work—through phone calls, emails, social media, or mail.

Kara, a provider in a state with a ban, said that individual physicians at her clinic faced doxxing, the act of publicly exposing personal information such as phone numbers and addresses, which can lead to offline harassment and potential danger.[146]

In a state without such a ban, Daniel, another provider, said that his clinic became a target for online harassment after an anti-trans account with a large following circulated screenshots from his clinic's webpage.[147]

Renee, a gender-affirming care provider, stated:

I've received emails with graphic or gruesome pictures. I've had to show them to the FBI because some of them constitute child pornography. I have received mail, just unsigned letters, several pages long, hyper-religious things … about how I'm going to hell and rambling about sex and gender.

I think the thing that really bothered me the most though was the negative online reviews of my practice, because I am the only person who does what I do specifically with adolescent medicine in about a 30-mile radius.... I saw a dip in my practice, and I would say that if I had an appointment with a new provider for my kid and Googled them and saw some of the [reviews] that I saw, I would have some hesitation too.[148]

The number and timing of the negative reviews suggested that they were fabricated claims from people who were not patients. This harassment not only damaged her professional reputation but also created obstacles for families seeking care, as she is the only local care provider operating in her specialty.

A healthcare provider in a state without a ban in effect said that her institution received 15 emails requesting she be fired or disciplined due to her work supporting transgender youth.[149]

Grace, the mother of an 18-year-old trans man, said that her son’s clinic faced an arson attack, forcing it to move to online services and temporary pop-up clinics.[150] She highlighted the clinic’s resilience: “The thing about [the clinic] is that they go above and beyond to ensure that individuals receive the essential medical services they need.”[151]

Increased Security Measures

Clinics and hospitals offering gender-affirming services have adopted extensive and expensive security measures to protect their staff, patients, and facilities from violence and intimidation. Providers interviewed by Human Rights Watch described how their workplaces responded to this growing hostility, detailing the emotional, financial, and logistical toll of safeguarding their operations in a dangerous environment.

Kara, a medical provider, detailed how her hospital’s gender-affirming program responded to anti-trans hostility following the enactment of ban in her state. She said that the hospital implemented substantial security measures, including removing provider photos from their website, frosting clinic doors for added privacy, and installing panic buttons in key areas.[152] After two staff members were doxxed online, the hospital reached out to the FBI for assistance, she added. To minimize further incidents, they have kept a low profile and refrained from advertising, Kara said. These precautions were put in place in 2023, coinciding with heightened safety concerns following the passage of restrictive laws.[153]

Daniel, a gender-affirming care provider in a state without a ban in place, recounted that following the online anti-trans campaign targeting his clinic, his administration took precautions such as removing photos and profiles from their clinic’s website and hiring a security officer. Daniel shared his frustration over having to hire a security officer, given the negative encounters many of his patients have had with law enforcement; the clinic requested that the officer wear exclusively pedestrian clothing to minimize discomfort among patients.[154]

Colin, a gender-affirming care provider in a state with a ban in place, said that his hospital emphasized educating staff about the risk of “secret shoppers,” individuals posing as patients or parents who secretly record visits and share the footage on social media.[155] The clinic trained its staff to handle phone inquiries carefully and to be mindful of documentation and communication practices, Colin added.

While removing information from hospitals’ websites can help protect staff safety, it also creates barriers for patients seeking care by making it harder to find and connect with providers.

An LGBT rights organizer in a state with a ban in effect, a local gender-affirming clinic in her city was forced to temporarily close after receiving a bomb threat against the hospital and harassing phone calls. The intensity of threats led the clinic to switch entirely to telehealth for approximately eight months. During this period, one doctor continued providing care by conducting telehealth appointments from her basement, with security personnel stationed at her home for protection. After receiving death threats, she relocated out of state with her family. The threats affected the entire facility, triggering multiple clinic-wide lockdowns following an anti-trans rally in the city.[156]

Targeting by State Authorities

In states with bans on gender-affirming care, attorneys general and other state officials have increasingly used the power of their office to target healthcare providers and transgender patients.

Tennessee’s attorney general, for instance, sought and obtained medical records for 82 transgender patients from Vanderbilt University Medical Center (VUMC), causing distress among patients.[166] While VUMC complied and provided the records, institutions like Washington University in St. Louis pushed back, citing privacy protections and engaging in litigation to resist such demands.[167]

In Texas, this trend began in early 2022, when Governor Greg Abbott ordered investigations into families of transgender youth receiving transition-related care, based on Attorney General Ken Paxton’s claim that such care might be considered child abuse.[168] Paxton then sought lists of Texans who had changed their gender on driver’s licenses,[169] and investigated children’s hospitals even before Texas enacted its 2023 ban on gender-affirming care for youth.[170] After that ban disrupted or terminated care across the state, officials have subsequently taken action to prevent patients from obtaining care elsewhere. In November 2023, Paxton subpoenaed Seattle Children’s Hospital for records on Texas children receiving such care, though the hospital is contesting the demand as an unconstitutional effort to restrict out-of-state care.[171]

Human Rights Watch interviewed three healthcare providers from two states who received official communications from state authorities regarding gender-affirming care for youth.

At one gender-affirming care clinic in a state with a ban, two providers reported that their state’s attorney general sent a letter to several institutions in the state, including theirs, requesting details about their gender-affirming program for youth. Although the providers said the request did not affect their practice, they told Human Rights Watch that the state’s ban had a significant impact on their operations.[172]

Medical Records and Digital Surveillance

The expansion of digital surveillance has emerged as a mechanism for enforcing anti-trans legislation.[173] In Florida, for instance, Governor DeSantis required universities to surrender detailed information about students diagnosed with gender dysphoria or seeking gender-affirming care, creating what one lawmaker called a “borderline registry of trans people.”[174] Similar efforts occurred in Missouri, where a Kansas City hospital faced 54 requests by the state attorney general for patient health data,[175] and in Texas, where officials attempted to compile a list of over 16,000 people who had changed their gender markers on driver’s licenses.[176]

The growing digitization of medical records has created vulnerabilities for trans patients and gender-affirming care providers. In a state with a ban in place, a medical records merger revealed how data integration can compromise privacy: when records were consolidated, many transgender patients suddenly had their “deadname” (their former names) appear exclusively on medical records that had previously been updated with their correct name.[177]

The interconnected nature of medical record systems can inadvertently expose patients and families receiving out-of-state care as well as the providers treating them. Even when gender-affirming care is obtained in states where it remains legal, diagnostic codes and test results can appear in home-state medical records through national laboratory networks.[178] Law enforcement can access this personal data through various channels, including geofence warrants, which allow police to obtain location data from all cellular devices within a specified geographic area (such as near medical clinics);[179] warrants for digital communications and keyword searches;[180] direct purchase of personal data without warrants;[181] and health data sharing between providers.[182]

The number of warrants obtained by law enforcement for personal data has risen in recent years. Google data from 2018-2020 shows an increase in frequency, with several states that now have gender-affirming care bans among the top issuers of geofence warrants.[183] This trend of increased requests for user data from law enforcement In the US continued through 2023 and the first half of 2024, according to Google's transparency report on global requests for user information.[184] Similar trends have been documented in government requests for user data from Meta's platforms.[185]

Privacy experts have noted parallels between digital surveillance tactics used to enforce abortion bans and those potentially applicable to gender-affirming care bans.[186] In one case in Nebraska, law enforcement obtained Facebook messages as evidence against a teenager seeking to end her pregnancy, demonstrating how digital surveillance of communications can be weaponized to target individuals seeking care.[187]

Some states have attempted to address these privacy concerns through establishing greater privacy protections for health data.[188] However, one gender-affirming care provider in a state without a ban in place explained, this protection comes with healthcare risks: “Say one of my patients is in the ER at two o'clock in the morning and they can't remember what their blood pressure medicine is.... They're not going to get as prepared care because that person can't access the records.”[189]

III. Texas: Weaponization of Child Welfare Services

Texas has taken an extreme stance against gender-affirming care for transgender youth, implementing severe restrictions and involving the state’s child welfare agency, the Department of Family and Protective Services (DFPS), in enforcement. The state's aggressive approach has created a system of surveillance and punishment targeting families who support their transgender children.

In February 2022, Governor Greg Abbott issued a directive classifying certain gender-affirming services for youth as child abuse.[190] This directive mandated investigations and penalties for parents who support their children in accessing specific medications or procedures, potentially leading to the removal of their children from their homes. Healthcare professionals facilitating access to these services also face penalties, while various state officials are required to report any known use of the specified gender-affirming services. The measure also empowers any individual in Texas to report a family for affirming their child’s transgender identity via the agency’s hotline number. No other state has directly linked parental involvement in such a manner to allegations of child abuse.[191]

Since March 2022,[192] the directive has been mired in litigation, leading to periods of paused investigations followed by resumption with minimal clarity.[193] In June 2023,[194] Texas became the largest state to enact a ban on gender-affirming care for youth under age 18, threatening to revoke the medical licenses of doctors who provide treatments such as puberty blockers and hormone therapy.[195]

The state's commitment to enforcement became clear in October 2024, when Texas filed a lawsuit against Dallas-based doctor May Lau, accusing her of violating the state's ban.[196] The case is among the first of its kind in the nation, with Paxton seeking $10,000 in penalties per violation, a potential total liability of hundreds of thousands of dollars.[197] Dr. Lau also faces revocation of her medical license if found in violation of the ban.[198] That fall, Paxton filed additional lawsuits against two more Texas-based providers, Dr. Hector Granados and Dr. Brett Cooper.[199] In these filings, Paxton labeled the accused doctors as “radical gender activists.”[200] Granados is one of only two pediatric endocrinologists serving the El Paso region. The lawsuit has jeopardized his ability to continue practicing medicine, leaving hundreds of children—many with serious endocrine conditions—at risk of losing access to critical, specialized care.[201] Notably, in Granados’s case, two of the patients who are alleged to receive testosterone for transition are described as “biologically male” (that is, cisgender) in the lawsuit.[202] Senate Bill 14 does not ban the prescription of testosterone for cisgender boys.

Child welfare systems in the United States have a history of discrimination and harm directed toward marginalized populations. A 2022 Human Rights Watch report revealed significant racial and socioeconomic disparities within child welfare involvement, indicating that Black children are twice as likely to be separated from their families as their white counterparts.[203] LGBT families and youth have similarly faced discrimination within this system, both historically and currently.[204] Legal experts specializing in LGBT rights have observed that allegations suggesting a parent is coercing their child to identify as transgender have become a tactic in custody disputes, particularly in cases where one parent does not affirm the child's gender identity.[205]

Since 2017, Texas began the roll-out of an initiative to restructure Child Protective Services through the privatization initiative Community-Based Care (CBC), which contracts non-profit organizations to manage case placements and services, allowing the DFPS to assume a supervisory role.[206] Faith-based organizations play a role in this system, as Texas collaborates with them to facilitate service delivery.[207] This can pose an additional threat to LGBT individuals who may be discriminated against by faith-based organizations,[208] particularly given that there are no protections for LGBT individuals in the state’s child welfare system.[209] In 2024, Paxton sued the Department of Health and Human Services (HHS) over a rule introduced by the administration of President Joe Biden that requires LGBTQI+ foster children to be placed in homes which are supportive of their identities.[210] In 2025, a federal court ruled in favor of the state, giving the DFPS authority to place LGBTQI+ foster children into unsupportive homes.[211]

Families with transgender children that have faced DFPS investigations are left shaken even when the investigation ends with no further action taken. In one such case, a parent interviewed by Human Rights Watch said, “When we got the call that we were under investigation for child abuse, it felt as if the wind had been knocked out of us. It was the most traumatic thing we had ever experienced.”[212] The DFPS investigator acknowledged the parents’ concern for their children’s well-being, remarking, “Clearly, you’re doing something right,” which left the parents feeling both reassured and uncertain about their future.[213] Reflecting on the experience, the parent said, “It feels like a constant balance of knowing our child is thriving while also living with the fear that the state could tear our family apart at any moment.”[214] The emotional toll of the investigation on the family was devastating; their younger, cisgender child experienced a significant mental health impact, including expressions of suicidality, and ultimately required inpatient care, changes caused in large part by the DFPS investigation, the parent stated.

The risk of DFPS investigations and the state's anti-trans climate led the mother of a girl in Texas to ask her daughter to conceal her trans identity. The mother cried as she recounted this decision:

I hate myself for being afraid. I want to be an advocate, and I want to be like, I'm totally proud of you. I tell her, I'm totally proud of you; you can be whoever you are, you are a treasure.... I just get so scared. It's a terrible place to be in because you want to be there for your child, and you want the whole world to affirm them. And then if the world is not an affirming place, it's really hard.[215]

Her daughter added: “It feels wrong to have to keep something that I am [to myself]. Nobody gets to know about it… [but] you just really don't know how anybody will react when you tell them that sort of thing.”[216]

The mother stated:

In Texas, it is illegal to raise your child in an affirming way.... The law says she [the faith community member] could call CPS [Child Protective Services] on me, which is scarier to me than going to jail, just that someone could decide that she [her daughter] should be taken away from us.[217]

Reflecting on the hostile environment, the mother described her ongoing fear “that at any point someone could decide they don't like us and they're going to make our lives really miserable. And everyone's empowered to do that in Texas, which is awful.”[218]

In another part of Texas, a trans girl said that the state’s policies had severely impacted her mental health and sense of safety. The DFPS directive compelled her to hide her identity to protect herself and her family, she said. Coupled with the stress of anti-trans laws, her depression grew, causing her to miss around 30 days of school in a single year. She said:

It feels like [I am] a pariah from the community because of these specific laws.... It’s basically forcing me to go into hiding.... Not only would I have the medicine taken away from me, but without the medicine, I would go through male puberty and then I would have my family taken away from me.[219]

She added:

I had to basically be hidden from the public for a while and not really do anything…; it felt like I had been exiled. If I had to go out, I would stay kind of quiet but not really want to draw more attention. I had become much more socially awkward… and it's not because of lack of wanting to make friends. I do want to make friends. It's just the fear.[220]

As she continues to grapple with these challenges, she reflected: “It’s a little bit harder to get back into being social again and being more out there.... It’d be much nicer to not have that weight on my back of constantly having to look over my shoulder.”[221]

The girl's mother said that the family is afraid to seek medical care for non-gender-related health issues due to the state’s DFPS directive and the unclear wording of Texas’s ban on gender-affirming care. She said: “If I took her to a doctor and mentioned she was on hormone replacement therapy, I would incriminate myself and put her at risk.”[222]

To protect themselves, the family travels with “safe files,” including letters from doctors and the daughter’s updated birth certificate, which reflects her correct gender. The mother said she hoped that this documentation would shield them if they were ever questioned by state officials.[223]

The repercussions of Texas’s anti-trans political climate extend beyond families, affecting healthcare providers and civil society organizations. A mental health provider who is also the parent of a transgender child expressed her fear of losing her professional license for supporting her child's care.[224] In addition, an LGBT organizer highlighted concerns about the involvement of faith-based organizations in the child welfare system. They noted that following the privatization of certain DFPS functions, their organization received emails from the state office promoting faith-based practices, including guidance on leading prayer circles for children who have experienced abuse.[225]

This growing influence of faith-based organizations in the increasingly privatized child welfare system, coupled with the lack of protections for LGBT youth, has compounded challenges for families seeking support. Healthcare providers are compelled to choose between delivering necessary, affirming care and safeguarding their professional licenses. Meanwhile, families face the dilemma of prioritizing their children’s medical needs while fearing potential state intervention.

IV. Impact of Gender-Affirming Care Bans on Healthcare Systems

The ramifications of bans on gender-affirming care extend beyond the youth they are designed to target, significantly affecting transgender adults and already strained healthcare systems. As healthcare providers grapple with the fear of legal repercussions and increasing hostility, many have felt compelled to cease offering services to trans patients altogether or relocate to states with more supportive policies. This exodus has resulted in longer waitlists, fewer care options, and diminished access to essential medical services for everyone, including those who may require care for a wide range of health issues unrelated to gender-affirming care.

The cascading effects of these legislative actions create a healthcare crisis that harms not only transgender individuals but also the broader population, exacerbating existing disparities and straining already overburdened healthcare systems.

Spillover Effects of Bans for Trans Adults

The impact of bans on gender-affirming care extends beyond the youth they explicitly target, spilling over into care for transgender adults. Physicians, fearful of legal consequences and growing hostility, have moved out of states with bans in place or have stopped providing services to all trans patients regardless of age, leading to longer waitlists and fewer options for care.

Eli, an LGBT organizer in a state with a ban on gender-affirming care for youth, said that seven local practitioners, including two endocrinologists, have ceased providing gender-affirming care to adults. The result, Eli said, has been longer waitlists and fewer options for care. “We’re losing a lot of places where we can go to the doctor.... We’re having to leave primary providers we’ve had for years because they’re no longer comfortable treating trans patients,” he said.[226]

His organization tries to connect trans people with affirming doctors, but the situation is worsening. “Now so many [clinics] are overwhelmed and not taking new patients. And the affordable places, like clinics that take Medicaid, are full,” he added.[227]

Ali, a researcher focusing on the impact of restrictions on gender-affirming care, noted that this fear of legal prosecution or social backlash deterred doctors who might otherwise be open to learning: “Instead of fostering learning, these punitive measures make them fearful to even treat a trans patient for gender-affirming care.”[228]

Carol, an LGBT organizer in a state with a ban, stated:

Providers are scared to give this care because they don’t want violence enacted against them. They don’t want that target on them. It’s not just that they’re restricting our health care, it’s that we’re losing access to good doctors who are knowledgeable in HRT [hormone replacement therapy] and trans care because those people are moving out.[229]

By stoking fear, these laws could have the effect of severely or totally curtailing trans health care.

In Florida, Senate Bill 254 not only banned youth access to gender-affirming care but also

imposed strict restrictions on adult care.[230] The law requires transgender patients over 18 to provide informed consent using forms authored by state agencies which some trans advocates have called misleading.[231] The law also requires that informed consent must be provided in person and has barred non-physician providers from offering this care,

limiting the use of telehealth and care from nurse practitioners.[232] This change has

impacted access in Florida, where much of the care was previously provided remotely or by non-physician providers.[233]

A LGBT rights advocate in Florida, explained the strategy behind these restrictions:

The slogan, the campaign, everything said, “Let kids be kids.” … Then the rule comes out, and it bans coverage for all adults and minors. It was never about kids.[234]

In 2024, 13 states,[235] including Florida,[236] Iowa,[237] North Carolina,[238] Tennessee,[239]

Utah,[240] and Wyoming,[241] proposed bans on adult access to gender-affirming care. The

minimum age for access varies by bill. For example, a bill introduced in Kansas would ban gender affirming care for individuals under 21,[242] while legislation in Oklahoma initially sought to prohibit care until 26, though it was ultimately lowered to 18 following resistance and advocacy from LGBT advocates.[243]

Meanwhile, the mental health toll on trans adults has become more severe. Kara, a provider of gender-affirming care in a state with a ban, said:

In our adult patients, there's definitely been a mental health decline. Our psychiatrist mentioned it the other day—patients are scared, sad, and overwhelmed. Many are figuring out how to leave the state, and some are even considering leaving the country.[244]

Medical Shortages and Straining

Bans on gender-affirming care may exacerbate shortages of providers in states where these laws are enforced, deepening healthcare disparities and straining systems that were already under-resourced. These bans, alongside restrictions on reproductive care, are driving away professionals.

States with bans on gender-affirming care already face severe shortages of pediatric providers. According to data from the American Board of Pediatrics, states with these bans have only one-third the number of adolescent medicine providers compared to those without.[245] Before the bans, families in rural areas had to travel long distances, as most clinics were in urban centers. Eighty percent of rural counties already are designated as medically underserved;[246] experts warn that gender-affirming care bans,[247] alongside restrictions on reproductive care,[248] will exacerbate this strain.

Chloe, an LGBT organizer in a state with a ban, highlighted these challenges.[249] Her state had only two pediatric endocrinologists before the ban, both treating transgender youth and children with conditions like Type 1 diabetes. One doctor, she recounted, ran satellite clinics in rural areas but, after the ban, he felt compelled to reduce services in the state with restrictions. Many needing pediatric endocrinological care in her state now face travel times of up to eight hours as a result.[250]

Ethan, an LGBT healthcare advocate in another state with a ban, stated:

We've lost a lot of providers [due to] the abortion ban and the youth health care ban.... People go through school here and then leave immediately when they graduate. A lot of that is because providers don’t want to practice somewhere where they can't uphold their ethics.[251]

Colin, who works at an institution that previously had a robust pediatric gender-affirming care program, described how the ban forced the program to halt almost all services for those under 18 and impacted the hospital’s ability to recruit new medical students. He explained: “Before the ban, for residents of medical students interviewing for pediatrics, the presence of the gender program was an important plus.”[252]

Olivia, a gender-affirming care provider in another state with a ban, stated:

[Hospitals] are having a much harder time recruiting new residents. The match is abysmal.... Nobody wants to come here. Before the ban, the gender program was a big plus, but now medical students are asking deans about the ban. States with these bans are losing their ability to attract the best and brightest, and the students we are training are disproportionately leaving for residencies in other states.[253]

The long-term effects of under-recruitment due to legislation—whether from bans on gender-affirming care or abortions—are still unfolding.

As Olivia said:

I fear that once you hit the end of a 10-year period from the start of this stuff ... Especially with gender-affirming care and Dobbs smacked together... you're going to have a dearth of medical providers in banned states and a surplus in non-banned states. I wish it were more equitably allocated.[254]

Prevalence of Conversion Practices

Conversion practices—deliberate efforts to change someone's sexual orientation or gender identity—have been uniformly rejected as harmful by leading medical organizations, including the American Medical Association, American Psychological Association, and American Academy of Pediatrics.[255] These practices, which can occur in medical, religious, or commercial settings, have been linked to severe mental health consequences including anxiety, depression, self-harm, and suicidality.[256]

Among states that ban gender-affirming care, only Utah has also enacted significant protections against conversion practices for youth.[257] The remaining 27 states allow conversion practices for youth despite the medical consensus that they can cause serious harm.

Healthcare providers have witnessed the impact of these practices and expressed concern that restrictions on gender-affirming care may push more families toward conversion practices. Colin, a gender-affirming care provider in a state with a ban in effect, reported that at least one in ten youth at his clinic disclosed experiences with conversion practices, though he suspects the actual number was higher as many choose not to reveal this history.[258]

Shauna, a psychologist at an in-patient mental health program in a state with a ban in place, estimated that one in five of her transgender patients have been subjected to faith-based conversion practices.[259] She noted that increasing anti-LGBT rhetoric has led some parents, feeling “embarrassed,” to seek out these harmful interventions. She explained:

Parents go to their communities for answers, and they find this misinformation. And then the solution is they need to see more God.... They're like, oh no, I have to fix this and let me get on Facebook, let me text some people, and [they say you] need to go to church.... Parents are looking for solutions to change the children.[260]

The situation may worsen in states banning gender-affirming care. Molly, whose clinic had to stop serving trans youth under 18 after her state passed a ban, said:

[In my state], we don't have bans on conversion therapy. Who will we start to attract? Will we repel affirming mental health providers and attract more hostile ones? I think this will take time to play out as we go through cycles of training and hiring, but the full consequences might not be seen for a few years.[261]

These policies risk creating a dangerous healthcare vacuum, driving away affirming providers while potentially attracting those who exercise harmful conversion practices.

V. Self-Censorship and Social Withdrawal

The increasing hostility toward transgender youth and their affirming parents has compelled many to navigate their lives in “stealth,” concealing their gender identity or their child’s gender identity to evade harassment, violence, or legal repercussions. Most interviewees stated that the consequences of this underground existence have forced families to decide between public expressions of support for their children and being able to protect their children. As families are forced to limit their visibility to close circles, the community of support for trans youth diminishes, leaving many deeply isolated.

Eli, a transmasculine individual and father of a trans daughter, said this climate has forced both him and his daughter to mask their identities for safety. Public spaces, where he is frequently misgendered, are fraught, he said. “We’ve talked about it, and we just stopped correcting people anymore because of how dangerous it is right now,” he explained.[262] Despite the pride he feels in their identities, Eli said, survival has become more of a priority: “It’s not fair that we have to mask our identities like this [to be safe].”[263]

To manage this, Eli and his daughter created a “script” to navigate social interactions safely. He recounted that he told his daughter, “When we go out, let’s not talk about the fact that you’re trans. If somebody calls me your mom, don’t correct them.”[264] Eli reflected on the impact of identity suppression on his daughter: “Having that kind of restriction is really hard for her. It’s heartbreaking.”[265]

Hannah, the mother of a 10-year-old trans girl, Lily, said anti-LGBT policies in her home state, which the family has since left, affected her family: “We were much more careful about sending her places. We always made sure that there was at least one adult who knew and was okay with her being transgender in case something happened.” Hannah said Lily “wants to tell everybody everything all the time.” Hannah recalled having to explain to her daughter: “You can't talk about being transgender unless we've told you that person is safe or unless we are there with you.”[266]

Chloe, an LGBT organizer in a state with a ban, told Human Rights Watch that parents maintained their children’s stealth status for as long as possible, navigating fear of being discovered and exposing their child to hate.[267] Ethan, a LGBT healthcare advocate in a state with a ban, said that hostility begets isolation. “[Trans] people log onto social media every day and see people debating whether they [trans people] should get to live,” he reflected. The constant exposure to transphobia, Ethan said, has led many trans people to feel isolated, fearful, and alienated from potential support.[268]

LGBT rights organizers told Human Rights Watch that the many anti-LGBT laws and policies—including bans on gender-affirming care, bathroom restrictions, and forced outing measures in schools—have come to function as instruments of repression. In 2024, 93 percent of total transgender youth between ages 13 and 17 live in states that have proposed or passed laws restricting their access to health care, sports participation, and facility use.[269] These laws and policies stifle the agency and rights of individuals, extending beyond their explicit and often vague legal mandate to restrict a range of activity.

Molly, a gender-affirming care provider, said that because of this climate, parents have become hesitant to advocate for their transgender children in public spaces, such as schools, due to fear of how others would react to their family. “While this doesn’t mean they [parents] are invalidating their children,” Molly clarified, “the pressure to remain silent has reduced their ability to publicly support their kids.”[270]

Maya, a civil rights attorney, said:

My biggest fear is meeting parents every day who are unsure—should I let my child be themselves?... Now, with information being circulated that supporting your child could be labeled as child abuse, parents are terrified. Most would feel forced to stop affirming their child if they thought CPS [Child Protective Services] might take them away. That’s horrifying.[271]

Though Maya doesn't work in Texas, where the state's child welfare agency was ordered to investigate families affirming their child's gender identity, the ripple effects have sparked fear nationwide. Carol, an LGBT rights organizer in a state with a ban, added: “People are scared they're going to lose their kids. And so it's almost like you don't have to legislate it if you scare people so hard that they almost self-police.”[272]

Tessa, an LGBT organizer in another state with a ban, described how vaguely worded, hard-to-enforce laws, such as bathroom bans, are intentionally designed to create fear, stating that “the chilling effect is by design.”[273]

Carol said that several LGBT youths she’s worked with have gone “missing.” She recounted:

We helped support a lot of kids who weren't out to their parents, couldn't be out to the parents for safety reasons. I've had a couple of kids disappear, and I asked, where's [child’s name]. And they're like, “Her parents found some stuff in her backpack, and found out she was trans. And they sent her to conversion therapy, sent her off to a camp,” and that was two years ago. Neither me nor the other kids have heard from that child since then. And there have been a lot of cases of that, even just within the [institution where she works].[274]

Another LGBT organizer and parent of a trans youth said:

We had so many families from the[LGBT] center disappear. They moved. We were pivotal in helping relocate many of them, but the ones that are stuck behind are the ones who are not the most privileged. These are the families that are on Medicaid, they can't afford to be paying anything, let alone relocating to another part of the country. So it's kind of like, for me, the battle is not just for my children, it's for the other 200 something families that I know of here who don't have that option, and those families have all gone underground. So everything has become suddenly like an isolated island. So we are out there and we're putting our voice out there, but we are alone because everybody who used to be part of our community is now hiding and they don't come up anymore at all for anything.[275]

Tessa, an LGBT organizer in another state with a ban, observed a significant decline in attendance from trans youth and trans parents at support groups:

Personally, I know of probably about three or four families [who relocated]. Sometimes you just don't hear from them. Again, it's hard to say what has happened to them.... I have tried to make sure that they're aware when the group meets and stuff like that, but I suspect that people are being a little more careful as well. I think that's part of the equation.[276]

To address these challenges, Tessa’s LGBT center has implemented measures to make support groups for both trans youth and adults as discreet as possible, while still expressing pride publicly. She explained, “One of the things we do is hold the group after hours here at the center. As soon as the kids walk in, we lock the door. I think there are a lot of folks who are very scared to be visibly trans.”[277]

VI. Chilling Civil Society: Harassment, Fear, and Burnout

The hostility toward transgender people has created an atmosphere of intimidation that threatens the infrastructure of trans advocacy. Civil society actors, including community organizers, legal advocates, healthcare providers, educators, and grassroots leaders, are facing escalating harassment, violence, and surveillance. This pressure has forced many to scale back their visibility, restructure programming, increase security, or abandon public advocacy altogether.

Targeting, Harassment, and Violence

A trans woman and organizer in a state with a ban on gender-affirming care said that following an anti-trans rally in her city, she and her peers became targets of harassment. “I know 10 to 15 people personally who, since an anti-trans rally was held, have had people show up to their houses,” she recalled.[278] During the rally, the organizer was publicly outed on X, formally Twitter, by a prominent anti-trans media figure leading the event. She told Human Rights Watch that she had to delete her social media accounts to protect herself because she suspected people were “searching for my identity.” At the time, she was less visible, allowing her to evade the worst of the harassment. Many of her friends received “actual physical threats to their lives.”[279]

The organizer emphasized the increased need to “pass”—present oneself as cisgender—in order to ensure her safety.

Every time I leave the house, I need to make sure that beat is on. I need to make sure that my face is on that, frankly, that I'm not looking Clocky [visibly trans], when I used to be able to throw a hoodie and some sweatpants on to go to the store, [but now] I have to make sure that I'm presenting in a way that's not going to end up with me in the hospital. And it's that, but also having to teach [that] to, I call them baby dolls, the freshly out trans people.[280]

She recounted the various mechanisms threatening trans people: “It’s the political, it’s the interpersonal violence, it's the cultural shift.”[281]

In 2023, a group of anti-LGBT individuals defaced paintings depicting LGBT people on the walls of the center where Tessa works, covering them with biblical quotes as well as homophobic and transphobic messages. The year before, the organization received threats after promoting an event featuring drag queens.[282]

Another LGBT organizer in a state with a ban said that after her organization held a “drag story hour” at a Trans Day of Visibility event, she received emailed photos of her child, who is trans, accompanied by messages condemning her child’s appearance and gender identity. In addition, a cyber-attack flooded her inbox with over 3,000 spam emails in various languages, making it hard to manage essential communications like bank statements and medical records until she manually sorted and deleted each message. [283]

Maya, a civil rights attorney in a state with a ban, said that her advocacy has made her a frequent target of harassment:

Every time we file a new case, get an order, or I do a PR interview that gets traction, there's an increase in [harassment]. Sometimes its handwritten letters sent to my office, other times it's emails, or Facebook and Instagram messages, or comments on our posts. People have called me a child abuser, child molester, groomer.[284]

In 2023, Maya worked on a high-profile trans rights case, prompting severe harassment that necessitated increased security measures. “We had to hire a full security detail during the trial to escort us to and from the courthouse, which is a surreal reality,” she explained. Around the same time, her office installed security cameras to enhance safety.[285]

Three civil society members told Human Rights Watch that they had purchased firearms or began carrying guns they already owned for self-protection. One LGBT organizer said her organization had shifted its focus from community-building events to self-defense training: “We’re hosting [self-defense] classes, concealed carry trainings, and trying to form queer gun clubs. [We have also] beefed up security at events, taking a more proactive stance [to ensure safety].”[286]

Pride Parades and Rallies

According to interviewees, Pride events, celebrated for their visibility and affirmation of LGBT identities, have become targets of threats and violence, leading to heightened anxiety and changes in participation.

Tessa, a Pride organizer, said that escalating safety concerns at her city’s events led the organizers to invest in increased security measures, including metal detectors, bag checks, and snipers on rooftops.[287] As a result, the security budget for the event quadrupled between 2022 and 2023, Tessa said.[288]

Maya suggested that threats of violence and the presence of armed counter-protesters, including hate groups displaying Nazi flags, created a climate of fear and deterred many from attending a rally celebrating trans youth, despite their enthusiasm.[289]

Police Violence

While many responses to anti-trans violence center law enforcement, advocates and trans individuals reported that law enforcement officials are frequently perpetrators of anti-trans violence, both through direct violence and systemic negligence. LGBT advocates have observed underreporting of violence against trans people due to fear of contacting law enforcement or the misgendering of victims in police reports. This is partly due to individuals’ fear of contacting the police or because incidents are not considered hate-based crimes.[290] Additionally, police reports often misgender trans individuals, making accurate documentation difficult. As Carol explained: “When we talk about hate crime rates or we talk about trans murders and how hard they are to document, it’s because in a police report, if my driver's license says I'm a male, I'm going to be filed as a male.”[291]

LGBT organizers like Leo expressed frustration over police inaction, citing a case in which a trans woman survived an attempted shooting, yet authorities failed to investigate thoroughly.[292]

A 2024 American Civil Liberties Union report found that more than one in four trans individuals had experienced physical violence by police, with Black trans people being the most targeted.[293]

Many trans individuals are less likely to contact the police than their cisgender counterparts, including gay, lesbian, and bisexual people, due to fear of further mistreatment.[294] The police violence that transgender people face is both racialized and gendered.[295] For trans people of color, the intersecting oppressions of racism and transphobia amplify the likelihood of being targeted by police. Luca, a 21-year-old Black non-binary person, shared: “I don't feel safe seeing [the police]. If anything, I feel more at risk.”[296]

Eli, a LGBT organizer in a state with a ban in place, explained that as access to gender-affirming care decreases, many in his community face severe mental health crises. Instead of contacting the police for wellness checks, Eli has found alternative methods to avoid police intervention: “For queer people who haven't been able to get access to their meds, who are literally going into psychosis ... I’m trying not to call the police, [I’m] literally calling a DoorDash and [asking], ‘can you see if they're there?’”

In response to the lack of police protection, an LGBT organizer said she is working with marginalized communities to foster self-sufficiency and self-defense. She stated:

We can't rely on the police to choose us in [a violent] situation. We cannot rely on a crowd to stop someone from harming us.... In an ideal world, we would not have to live this way, but we don't live in an ideal world. We live in this world, and so we're having to take steps to protect ourselves. We have regular first aid trainings, stop-the-bleed trainings. One thing that we're trying to do right now in community groups is to make sure that all of our bartenders and staff at queer bars are stop-the-bleed trained and that they have trauma kits under the bar.[297]

Resource Depletion and Burnout

The relentless wave of anti-transgender legislation has taken a severe toll on advocates, healthcare providers, and community leaders, draining resources from communities. Many described their exhaustion from fighting what one provider called “this ridiculous fight that no one asked for.”[298]

LGBT organizers and gender-affirming care providers interviewed by Human Rights Watch shared that the strain has created a leadership vacuum as experienced organizers and mentors flee hostile states. Chloe, a LGBT organizer in a state with a ban in effect, stated: “It feels like we’re losing our foundation.”[299]

One organizer explained how younger members of the community are prematurely thrust into leadership roles: “I'm 29, I've been out [as trans] for three years.... I am almost an elder in this community because all of the people who were my older siblings who helped me through transition are gone now. They've either died, they've committed suicide, or they fled the state.”[300]

The legal battles alone have drained resources. Maya, a civil rights attorney, said that cases could cost over a million dollars to litigate, with each taking a personal toll on time and mental health:

They [lawmakers] recognize that the more horrible laws they pass, the less capacity we're going to have. And I think it's the saddest but best strategy I've seen to wear down the opposition.[301]

Similarly, healthcare providers have reported being forced to abandon other work to fight these restrictions. Renee, a physician, stated:

The amount of work that this [defending gender-affirming care] takes is astronomical. There were weeks and months where all I was doing when I wasn't seeing patients was writing or preparing for a case, preparing for a trial or something.... I was supposed to be building capacity for medical education in my field in lower resource settings.... And it [bans on gender-affirming care] was just so egregious and wrong and offensive and threatening to everything that I stand for as a clinician that I had to run to the fire.[302]

VII. Impact of Executive Actions by the Trump Administration

In early 2025, the administration of President Donald Trump issued sweeping executive orders targeting transgender rights, including a January 28 order that attempts to restrict access to gender-affirming care for youth.[303] These orders reshaped the national landscape for transgender rights in the US.

The January 28 order instructs federal agencies to ensure that hospitals, medical schools, and other medical institutions that receive federal funding for education and research cease the provision of gender-affirming care for individuals under 19. It also directs agencies to eliminate access to such care through federal healthcare programs, including TRICARE and the Federal Employee Health Benefits Program.[304] The order conflates evidence-based medical treatment with child abuse, laying the groundwork for potential criminal and civil penalties.[305]

Other executive orders issued in quick succession include a January 20 order that calls for the elimination of any recognition of gender identity in federal documents and programs,[306] a January 27 order that instructs relevant agencies to ban open military service by transgender individuals,[307] a January 29 order that which threatens to cut funding from schools that affirm students’ gender identities and discourages support for transgender youth ,[308] and a February 5 order intended to ban transgender women and girls from participating in women’s sports.[309]

These actions follow a 2024 election cycle that heavily featured anti-transgender rhetoric.[310]

While the January 28 executive order faces ongoing legal challenges,[311] several major healthcare institutions—in cities such as New York,[312] Los Angeles,[313] and Washington, D.C.[314]— responded by pausing gender-affirming care for youth while they assessed compliance risks, according to reported accounts. Some clinics have reportedly canceled appointments on short notice, leaving patients without care or guidance.[315]

Some states with robust anti-discrimination protections have pushed back. On February 5, 2025, attorneys general from fifteen states issued a joint statement affirming their commitment to protecting access to gender-affirming care.[316] They wrote: “State attorneys general will continue to enforce state laws that provide access to gender-affirming care, in states where such enforcement authority exists, and we will challenge any unlawful effort by the Trump administration to restrict access to it in our jurisdictions.”[317]

Healthcare and legal organizations have noted that broad or unclear directives may lead institutions to preemptively limit services—the practice known as “overcompliance,” discussed earlier in this report—in order to avoid legal risk. In some instances, this has included discontinuing services in states where no ban exists.

While most research for this report was conducted prior to President Trump’s inauguration in January 2025, 11 follow-up interviews were conducted afterward to assess early developments. Interviewees reported changes in access to healthcare services, increasing security measures at clinics, and difficulties navigating legal documentation processes under new policy conditions.[318]

Increasing Hostility

Jenny, a 17-year-old trans girl in a state where gender-affirming care is banned, said, “Since Trump was inaugurated, I’ve noticed more people being negative toward me. People are more bold now. I’ve faced more harassment from my peers.”[319]

She recounted a recent experience at school: “I was helping some of the new members of our club when a group of students started taking pictures of me and laughing. One of them said, ‘I can’t wait for Trump to crack down on this.’”[320]

Jenny added:

Most of what I face is actually from the school administration and from parents. Parents say they don’t want their kids using the same bathroom as a trans person or rooming with me [on overnight trips]—even when those students are totally comfortable with it. Since this issue has gotten more attention, the school made a policy that trans students can’t room with friends on overnight trips.[321]

Esther, the mother of a 15-year-old trans boy living in a state with a ban on gender-affirming care, described how her community had changed: “Three or four years ago, it wasn’t cool to be mean. It wasn’t cool to be transphobic. Now it’s totally socially acceptable to be mean, to make hateful jokes, to have uneducated opinions and spread them around.”[322]

Deteriorating Mental Health

When Liza, a 27-year-old trans woman, died by suicide just days after the 2024 US presidential election, her mother, Terry, said her daughter was consumed by the political climate leading up to the election, which she described as “a huge detriment to her mental health.” She continued, “There was a huge correlation between her well-being and what was going on in politics. Trump’s anti-trans agenda was so much more open and blatant than it was in 2016.”[323]

When Donald Trump won the election, Liza’s mental health deteriorated, Terry said. Just over a week later, Liza ended her life.[324]

Terry recounted her experience visiting Liza just a few months before the election:

She made us food, and I took her shopping. She asked me to go to Goodwill and help her pick out clothes. We were bonding as mother and daughter, and I’m so thankful for that time,” she recalled. “I finally felt like she was safe, she had something to live for. She was starting to blossom—wanting to travel, wanting to connect with people. I thought, she’s finally starting to live.[325]

Jenny, a 17-year-old trans girl in a state with a ban on gender-affirming care, said: “It’s scary to think about what my future is going to look like. Even if I go to a blue state for college, I might not be safe. There’s so much uncertainty. Will I have access to care? Will I be able to live as myself? That anxiety is always with me.”[326]

She explained that while state-level attacks on trans rights were already distressing, she used to feel a measure of protection from federal leadership: “I used to have that federal safety blanket. Now it feels like every level of government is turning against us. It’s hard to feel safe in your own country, in your own community and that’s terrifying.”[327]

Paulette, the mother of an 8-year-old trans girl in a state with a ban, described her reaction following the announcement of new anti-trans policies: “I couldn’t believe it was all happening and so fast. There was so much support for these horrible policies.”[328]

In the wake of the election, she reflected on having previously shared her daughter’s story online:

I thought I was doing the right thing by sharing our story, by helping people understand. For a while, it felt like it was working. People were supportive. They knew her, and she was the only trans kid they knew. But now I look back and wonder: “Did I endanger her?” I never imagined we’d end up here. I never thought I’d be deleting [from social media] anyone I didn’t know personally out of fear they’d report us or dig up old photos from before her transition. I just never thought we’d move so far backward.[329]

Jenny added:

Supportive groups and lawmakers have kind of shunned away from talking about trans people. They’ve chosen to fight other battles. It’s really sad to see people who claim to be allies, who say LGBTQ rights are part of their platform, and then do nothing to protect us.[330]

Paulette echoed this sentiment: “I just imagine someone showing up on our doorstep to do a genital check, pulling our child out of our home, and having no power, no one to call. There’s no one left who supports trans kids and stands up for trans rights in these places of power.”[331]

Threats to Healthcare Access

Access to gender-affirming care for transgender youth has become more uncertain in some parts of the United States following recent legislative and executive actions. Families in various states have reported that clinics have paused services, reduced public communications, or adjusted treatment offerings. Some parents and young people expressed concern that continued access to care may be at risk in the near future.

Paulette, the mother of an 8-year-old trans girl, said, “Last week, after the executive order, the clinics in [a neighboring state]—which we would’ve gone to [for care]—started canceling all gender-affirming healthcare appointments for kids under 19, preemptively.”[332]

Samara, a 25-year-old medical professional in a state without a ban, said, “Our services dramatically changed after Trump.”[333] The clinic implemented heightened security measures, changed how lab orders were processed to better protect patient privacy, and stopped publicly identifying itself as a provider of gender-affirming care at the front desk. In the weeks after the election, the clinic also experienced a rise in new patients from out of state. [334]

Esther, mother of a 15-year-old trans boy in a state with a ban in effect, said her son continues to receive treatment at a local clinic because the facility has maintained care for youth who were already enrolled before the ban took effect. She noted:

The clinic has changed a lot since Trump came into office. They’ve expressed fear to me. They won’t do Zoom anymore and don’t want to be publicly visible. It’s like being an abortion provider—there’s real fear about being targeted or even shot.[335]

Esther added: “If he had no access to care—if he was forced to go through female puberty, to be called ‘she,’ to grow breasts and hips—that’s not him just having to tough it out. That’s not living. He couldn’t walk into school like that.”[336]

Her son, Mark, said, “I honestly can’t imagine a world where I wasn’t like this, because that’s always who I’ve been.”[337]

Jenny, a 17-year-old trans girl who lives in a state with a ban who currently travels out of state to receive care, stated:

I’ve been lucky enough to still get care, but I might not have that in the next few weeks or months. And that’s really scary to think about. If I got off blockers and estrogen, I'd start to go through male puberty. My voice would deepen, I would present more masculine. I can't imagine living like that and not having access to something that makes me be able to present how I feel on the inside. I don't know how I would live with that. I'd have to move out of the country, do anything to get access to that. I can't imagine a world without gender affirming care and it's horrible to think about.[338]

VIII. Legal Obligations

The United States has ratified or signed several international human rights treaties that affirm human rights that are threatened by efforts to ban gender-affirming care for transgender youth.

Right to Health

The International Covenant on Economic, Social and Cultural Rights (ICESCR),[339] which the United States has signed but not ratified, recognizes in article 12 the right to the highest attainable standard of physical and mental health. It obligates governments to ensure the right to health is enjoyed without discrimination based on race, sex, religion, or “other status,” which the Committee on Economic, Social and Cultural Rights interprets to prohibit discrimination on the basis of sexual orientation and gender identity.[340] While the covenant is not binding on the United States, its signature obligates it to refrain from actions that would defeat the treaty's object and purpose, including systematic denial of essential health care.[341] The Committee on Economic, Social and Cultural Rights has stated that the right to health encompasses the right to control one’s health and body and the right to be free from interference.[342]

The right to health explicitly includes accessibility of healthcare goods and services without discrimination. General Comment 14, which interprets the right to health, states that accessibility is defined by non-discrimination, physical accessibility, economic accessibility, and information accessibility. It states that “health facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups…” and that affordability of services must be equitable such that “poorer households should not be disproportionately burdened with health expenses as compared to richer households.”[343]

The right to health also includes the right to health information,[344] including evidence-based information for adolescents on sexual and reproductive health.[345]

The Committee on the Elimination of All Forms of Discrimination Against Women (CEDAW), which the US has signed but not ratified, has called on states in certain contexts to ensure that the costs for gender-affirming care are reimbursed.[346]

Rights of the Child

Under the International Covenant on Civil and Political Rights, ratified by the United States in 1992, children—all youth under the age of 18—have the right to specific protection by virtue of their status as children.[347] Families are also “entitled to protection by society and the State,”[348] and in line with this right, everyone, of any age, has the right to freedom from arbitrary interference with their family.[349]

Children’s right to protection and assistance should be informed by the foundational principles of the Convention on the Rights of the Child (CRC),[350] a treaty the United States has not ratified but which it actively helped shape.[351]

In particular, protections for children should reflect the foundational principles of the convention. These principles include the best interests of the child, which should be a primary consideration in all actions concerning children;[352] the right to freedom from discrimination;[353] the right of children to be heard on all matters affecting them and to have their views taken into account in a manner consistent with their age and maturity;[354] and the right of children to healthy development.[355]

Children and their parents have the right to protection against arbitrary interference with their family.[356] Article 5 of the CRC recognizes the rights and duties of parents to help their children realize their rights,[357] which includes making informed medical decisions in consultation with healthcare providers and taking into account children’s views in accordance with their age and maturity.

The weight of the medical evidence supports the conclusion that access to gender-affirming care serves these interests by improving mental health outcomes and reducing suicidality among transgender youth. Sweeping bans on gender-affirming care provide little or no opportunities to consider of the unique and particular needs of individual trans children and contain language on non-consensual surgeries on intersex infants that affirmatively threatens the rights of intersex children.[358]

State bans on gender-affirming care interfere with the rights of children and their parents to take appropriate medical decisions and, as discussed above, with children’s right to the highest attainable standard of health, including their right to health information.[359] More generally, denying gender-affirming care to youth who, in consultation with their families and healthcare providers, have established their need for such care and their desire to receive it, is inconsistent with these fundamental principles.

Nondiscrimination and Equal Protection

Article 26 of the ICCPR guarantees equal protection of the law without discrimination.[360] The UN Human Rights Committee has interpreted this to prohibit discrimination based on gender identity, among other grounds.[361] Laws banning gender-affirming care therefore constitute discrimination by denying transgender individuals access to medically necessary treatment for “gender dysphoria,” a condition which is based on one’s gender identity.

Right to Personal Autonomy and Development

International human rights law recognizes the right to personal autonomy, including in healthcare decisions. The ICCPR's protections for privacy and personal security encompass the right to make decisions about one's own medical care.[362] For transgender youth, access to gender-affirming care during adolescence can be crucial for healthy development and the realization of their right to personal autonomy.[363]

Recommendations

To State Legislatures

• Lift barriers to medically prescribed gender-affirming care in line with best practice standards for transgender health established by WPATH, the Endocrine Society, and other leading medical professional organizations across multiple specialties.
• Repeal existing bans on gender-affirming care and reject proposed laws and policies that would restrict access to such care.
• Enact legislation protecting access to gender-affirming care and prohibiting discrimination against transgender youth and their families.
• Ensure state Medicaid programs cover gender-affirming care.
• Enact comprehensive shield laws to protect access to gender-affirming care by:
  • Protecting providers and families against out-of-state investigations and prosecutions.
  • Requiring insurers to maintain coverage and preventing discriminatory rate increases for providers of gender-affirming care.
  • Safeguarding medical records and the personal information of patients, providers, and facilities providing gender-affirming care.
• Establish mechanisms to assist out-of-state families relocating in search of safer communities and access to gender-affirming care for transgender youth.

To State Medical Boards

• Develop clear guidelines for providers offering gender-affirming care that align with established medical standards.
• Protect medical professionals' licenses from out-of-state actions related to providing gender-affirming care.
• Provide resources and training to healthcare providers on best practice gender-affirming care standards and practices.
• Issue statements supporting best practice gender-affirming care when medically indicated.

To the US Congress

• Reject attempts to ban gender-affirming care nationwide.
• Retain legislative frameworks that prohibit sex discrimination in healthcare settings, and expressly codify protections against discrimination based on gender identity.
• Allocate federal funding for scientifically based non-partisan research on gender-affirming care outcomes and best practices.
• Ensure federal health programs cover the costs of gender-affirming care on the same basis as other forms of medically indicated care.
• Pass legislation preventing states from criminalizing interstate travel for medical care, including gender-affirming care.

To the Executive Branch

• Rescind executive orders that deny rights and recognition to transgender people and undermine access to gender-affirming care.
• Restore previous guidance recognizing gender identity discrimination as a form of sex discrimination within the executive branch and ensuring federal civil rights protections are enforced to protect transgender individuals.

To the Office of the Surgeon General

• Provide medically sound, evidence-based guidance informed by the experiences of trans youth and adults to states on the provision of gender-affirming care for transgender youth.

To the Department of Health and Human Services

• Provide medically sound, evidence-based guidance informed by the experiences of trans youth and adults to states on the provision of gender-affirming care for transgender youth.
• Ensure that transgender individuals are fully covered under public programs and services, and withdraw regulations and guidance that limit or exclude coverage for gender-affirming care.

To Local Governments

• Ensure local health departments and agencies have clear protocols for supporting access to gender-affirming care within the scope of state law.
• Allocate funding to support mental health services and support programs for transgender youth and their families.

To State Attorney Generals

• Issue guidance protecting providers who offer gender-affirming care to the extent possible under state law.
• Join multi-state efforts to challenge restrictions on gender-affirming care.
• Enforce existing non-discrimination protections that protect transgender individuals’ access to health care.
• Investigate discrimination against transgender individuals in healthcare settings, including cases in which medical facilities preemptively discontinue gender-affirming services despite no legal requirement to do so.
• Exercise prosecutorial discretion to decline to enforce restrictions on gender-affirming care that conflict with medical best practices.

To County Child Welfare Agencies and Officials

• Develop protocols that support transgender youth and their families rather than investigating affirming parents.
• Ensure child welfare workers receive training on supporting transgender youth.
• Maintain confidentiality with regard to the transgender status of parents and children in child welfare records.
• Partner with LGBT organizations to provide resources and support to families.
• Reject calls to investigate families for providing gender-affirming care to their children.
   

Acknowledgments

This report was researched and written by Yasemin Smallens, an officer in the LGBT Rights Program at Human Rights Watch.

Whitney Bunts, a consultant with the LGBT Rights Program, assisted with a portion of the research. The report was reviewed by Rasha Younes, director of the LGBT Rights Program; Ryan Thoreson, a specialist in the LGBT Rights Program; Joeseph Saunders, deputy program director; Bria Nelson, a researcher and advocate in the US Program; Julia Bleckner, a senior researcher in the Global Health Initiative; Deborah Brown, deputy director of the Technology, Rights and Investigations Division; Zach Campbell, a senior researcher in the Technology, Rights and Investigations Division; Juliana Nnoko-Mewanu, a senior researcher in the Women’s Rights Division; Judith Sunderland, associate director of the Europe and Central Asia Division; Yasmine Ahmed, UK director; and Michael Garcia Bochenek, senior counsel in the Children’s Rights Division. Meredithe McNamara, MD MSc, of Yale School of Medicine also reviewed the report.

Production and editorial assistance were provided by Audrey Gregg, senior Asia associate. Additional production assistance was provided by Travis Carr, publications manager, Fitzroy Hepkins, senior administrative manager, and Jose Martinez, administrative officer.

This report is dedicated to trans youth across the US whose rights are under attack; and those past and present who have worked to defend the rights of all trans people to exist.