As state-level restrictions and campaigns against gender-affirming care for minors have grown in scope and creativity over the past year, some transgender adults worry that they will become the next target.

That day is not here yet, advocates say, though efforts are underway.

“We’re in a ‘never say never’ moment when it comes to trans health care,” said Vivian Topping, director of advocacy and civic engagement of the Equality Federation, a coalition of state LGBTQ+ organizations. “But the attempts that have happened have not moved past committee, even in a state like Mississippi, even in a state like Missouri.” 

Mississippi introduced a failed bill early this year to ban gender-affirming care for anyone under 21. In Oklahoma, legislation with the same age limit fell through last year. Missouri tried and failed to pass a bill this year banning care for trans youth that included a vaguely written clause that could have affected adults: Legislators wrote that state health insurance plans renewed in 2023 would not be required to cover gender transition procedures without specifying any age requirements. 

But even as restrictions on transgender youths have moved forward, these proposals targeting adults have failed. Even if they passed, however, bills banning care for trans youth have weaker legal ground to stand on when applied to adults, because they would infringe on adults’ autonomy, said Taylor Brown, a staff attorney for the ACLU’s LGBTQ+ and HIV Project. 

“I think it would be very difficult for states to come in like they’re doing for minors and prohibit that kind of care outright with the same kind of penalties,” said Brown, who has litigated numerous cases on trans health care this year. 

Outside failed attempts at legislation, however, states are using other ways to limit gender-affirming care. The approaches are slower and less public, and sometimes defined by a lack of protective action rather than a direct restriction.

In 27 states, there is no law providing LGBTQ+ inclusive insurance protections, according to the Movement Advancement Project (MAP), which tracks LGBTQ+ policy. (Conversely, 24 states and Washington, D.C., prohibit transgender exclusions in health insurance coverage.) Arkansas is the only state in the country to have passed a law giving private health insurers permission to refuse to cover gender-affirming care with no age restrictions. That law remains blocked, most recently by a federal court last month. 

At least 15 states explicitly exclude gender-affirming care from their state employee health benefits, per MAP’s count as of June. Eight states currently exclude gender-affirming care from Medicaid programs. In Florida, the most recent state to join that list, the ban was quickly challenged and awaits a judge’s decision on issuing a preliminary injunction to block the law. 

Olivia Hunt, policy director at the National Center for Transgender Equality, believes that the ultimate goal of bills focused on trans youth is to force trans people out of public life and restrict gender-affirming care access for all trans people, regardless of age. 

“If you are trans or nonbinary in the United States right now, regardless of what state you live in, your right to health care is under attack,” she said. 

Restricting gender-affirming care access for adults could take a variety of forms, Hunt said, especially since many trans people already live in areas without it. Restrictions could look like a state redefining what gender-affirming care is covered in their “benchmark” or standard insurance plan; an insurance company charging more for hormones; doctors or nurses rejecting trans patients, which is not allowed under the Affordable Care Act, but is still a possibility in the current environment fueled by anti-trans bills, according to Hunt; or the only pharmacy or hospital in town invoking a religious exemption to a civil rights law that allows them to withhold prescriptions. 

“There are a lot of ways that access to gender-affirming health care, or just access to health care generally for trans people, can be harmed,” she said. 

Florida’s health department has asked the state’s board of medicine to institute a 24-hour waiting period for trans adults seeking hormone therapy or surgery — a waiting period reminiscent of some state-level abortion restrictions. At this point, advocates within Florida see their home as a “testing ground” or bellwether state for new anti-trans and anti-LGBTQ+ efforts. 

Nikole Parker, director of transgender equality at Equality Florida, said that she worries about how far proponents of anti-trans bills are willing to go to restrict care. Other local community members have told her that they are afraid of their care being taken away completely, or of private insurance restrictions following Medicaid restrictions within the state despite no other bills reflecting that push.  

While growing fears are understandable, advocates say, state-level bills that have been introduced are failing. And many emerging restrictions against transgender people are met with a flurry of lawsuits.  

More likely, advocates said, states would use Medicaid exemptions and insurance exclusions for gender-affirming care as a means to restrict medical care for trans adults. Federal officials have signaled that they are aware of the lack of policy protections — both the Biden administration and Democrats in Congress  have promoted measures to make attacks on trans health care more difficult. The Department of Health and Human Services has pushed for explicit protections for gender-affirming care offered through health insurance plans given through the Affordable Care Act, and two senators are pushing to loosen restrictions on testosterone prescriptions.

Hormone therapy and gender-affirming surgery are crucial parts of transition for many trans adults. Alleviating gender dysphoria and aligning gender expression with identity through these treatments can lower stress, reduce symptoms of depression and anxiety, and significantly lessen suicidal ideation. Similar benefits have been found for trans youth who undergo hormone therapy or take puberty blockers. 

In some parts of the country, accessing such care already ranges from the difficult to the impossible. For trans people in rural areas, those who can’t afford insurance battles, or those faced with discriminatory doctor’s offices, a lack of resources and support already keeps them from getting the care they need — no further bills or effort required. 

Some trans people already live in rural areas where the nearest clinic is a two or three hour drive, Parker said. More restrictions would just make accessing that care harder and endanger trans people who run out of safe options. 

“Taking away health care from trans people won’t stop them from being trans,” she said. “What it will do is cause folks to go back to black market hormones, and that’s extremely dangerous.” 

For Topping, one of the biggest consequences of anti-trans bills is the potential chilling effect on trans people trying to access care, the doctors they’re seeking that care from, and on trans people coming out. And although gender-affirming care is accepted among major medical associations, current campaigns driven by far-right influencers against hospitals providing the care could make that chilling effect worse, she said. 

The growing rhetoric fueling attacks on those hospitals, coupled with pressure on teachers governed by laws restricting school discussion on gender and sexuality, makes one California-based teacher nervous about coming out to her peers as a transfeminine person. 

The 36-year-old special education teacher, who asked to be anonymous due to not being out to most people in her life, knows that she probably lives in one of the best states to start her gender transition. She doesn’t feel threatened about her ability to access care. But even within her “liberal bubble” in the Bay Area, she’s heard parents at her school recycle the same anti-trans rhetoric she’s heard elsewhere — that trans people are “groomers.” 

“I can see in my mind someone just turning around, someone who’s known me and worked for me for a while, just calling me a ‘groomer’ right there on the spot,” she said. “To have such hostile rhetoric around something that’s changed my life in nothing but positive ways, it’s pretty terrifying.” 

Logan Casey, senior policy researcher and adviser for the Movement Advancement Project, pointed out that when states aren’t able to pass anti-trans bills, state actors find other paths to accomplish that goal. In Texas, that took the form of the state’s attorney general and governor calling for investigations into the parents of trans children for alleged abuse. In Florida, pursuing Medicaid regulations and petitioning the board of medicine are other routes taken that require no legislation, he said. 

“It’s about trans people more broadly, and even in states where they have focused on youth, that’s been basically like a foot in the door to attack and restrict health care for all trans people of all ages,” he said.

Within the last year, a lot of patients have told Quinn Jackson, a trans primary care doctor who practices in Kansas City, Kansas, that they are worried about losing their access to gender-affirming care. He sees patients from both Kansas and Missouri. 

“There is a pervasive, and I believe legitimate, fear in the trans community that that attack on our rights and our ability to access care isn’t going to stop with minors. That, with time, they will probably seek to reduce access to care at higher ages and eventually for everyone,” Jackson said. 

When patients share that fear with him, Jackson tries to be reassuring. He says that he and the clinic will remain unless they are forced to shutter — and that he can help facilitate referrals to other clinics if patients feel like moving is the best option.