Corrected 12:37 p.m. | Republicans hoping to elevate conservative messaging about health care and services for transgender individuals have followed the same playbook that they used to advance anti-abortion legislation: starting in the states, focusing initially on minors.

But now, that fight is blooming into one that conservatives see as a potent campaign issue in 2024. 

In early February, former President Donald Trump, who is running for president again in 2024, identified a series of actions he would take to restrict gender-affirming care if elected. Speaker Kevin McCarthy, R-Calif., hosted a Feb. 1 event condemning transgender girls participating in youth sports. And on Feb. 9, Sen. Josh Hawley, R-Mo., launched an investigation of the Washington University Transgender Center at St. Louis Children’s Hospital. 

By contrast, the Biden administration has focused on advancing gender-affirming care. During his State of the Union speech earlier this month, President Joe Biden called for the passage of a bill to amend the Civil Rights Act of 1964 to prohibit discrimination on the basis of sex, sexual orientation and gender identity. 

“Fighting the exploitative transgender industry is now Republican orthodoxy embraced by the party’s most popular leaders, and we expect this issue will only gain more visibility as the 2024 campaign shifts into full gear,” said Terry Schilling, president of the conservative think tank and super PAC American Principles Project, which spent nearly $16 million in the midterms advocating against transgender issues related to health and education. 

Schilling criticized Biden’s proposal, saying it would “weaponize the federal government against Americans who recognize basic biology.”

State roots

As with the abortion debate, the debate over transgender health has its roots at the state level, where advocacy groups often work to push model legislation.

“It’s not as if these are initiatives kind of organically happening in different states,” said Brad Sears, founding executive director at the Williams Institute and affiliated faculty at the Center on Reproductive Health, Law, and Policy at UCLA.

“With both abortion and trans rights, we’ve seen the restrictions kind of starting at the state level,” said Transgender Equality Task Force Co-Chair Pramila Jayapal, D-Wash., who is the parent of a transgender child and was one of the first lawmakers to speak publicly about her abortion. “I think there has been, you know, a real push now to make this the defining issue, along with abortion rights.”

In some cases, both abortion and gender-affirming care have been lumped together, with at least five states — Oklahoma, Wyoming, Iowa, Missouri and South Carolina — considering penalizing businesses for reimbursing employees for health-related travel costs to seek an abortion or gender-affirming care. 

Sen. Marco Rubio, R-Fla., reintroduced legislation that would deny business deductions for traveling to seek an abortion or gender-affirming care for minors.

The bills often include similar keywords.

Iowa lawmakers are considering a bill seeking to restrict gender-affirming care for minors, arguing “an individual’s sex is genetically encoded … at the moment of conception, and it cannot be changed.” Similarly, state abortion legislation often cites “conception” as a measure for when to prohibit abortion, even though medical experts measure pregnancy using the first day of a person’s last period.

Sen. Edward J. Markey, D-Mass., said the abortion and gender-affirming care, both “powerful movements for health justice,” “are interrelated.”

“Republicans are on a mission to put themselves in the exam room, wedged in between patients and providers, and are using disinformation as their tool of choice for this campaign of discrimination,” he said.

Policy parallels

Conservatives have advocated abortion restrictions specific to minors, criticized the science behind abortion, issued warnings about the safety of abortion methods, penalized abortion providers and amplified the experiences of those who later regretted the procedure.

They’re applying those same arguments to push back on gender-affirming care for transgender and nonbinary minors, which includes puberty blockers or hormone therapy.

“The same playbook that you’re seeing on access to abortion care is very, very, very similar to what we’ve seen with gender-affirming bans,” said Devon Ojeda, senior national organizer for the National Center for Transgender Equality. 

Efforts by Florida and Texas to limit and penalize gender-affirming care for adolescents and young adults gained national attention last year. Utah recently became the first state this year to ban hormonal treatment for anyone under 18 unless “medically necessary” — citing exceptions for conditions like precocious puberty and endometriosis. South Dakota followed suit in February.

Rep. Marjorie Taylor Greene, R-Ga., who spoke at the McCarthy event, introduced a bill during the last Congress that would make providing gender-affirming care to minors a felony.

“I don’t care if it’s a mental illness, I don’t care what it is,” she said. “It’s straight-up evil, and they do not belong in girls and women’s sports.”

Trans advocates warn that minor-specific restrictions could be a steppingstone to broader restrictions for adults. Some of the earliest abortion-related Supreme Court cases post-Roe v. Wade in 1973 centered on parental involvement and abortion. 

“We’ve seen bills that have been, that want to ban care for people under the age of 21 to 26 — and with the ultimate goal, of course, to completely ban gender-affirming care,” Ojeda said. 

As evidence, Paula Neira, program director of LGBTQ+ Equity and Education within the Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity and an assistant professor of plastic and reconstructive surgery, pointed to the Republican Party of Texas platform, which says to “oppose all efforts to validate transgender identity.”

Science-themed messaging is also evident in both pushes.

Last year, Sen. Lindsey Graham, R-S.C., citing science, updated the text of his bill he has introduced since 2014 that would prohibit abortions after 20 weeks, to 15 weeks.And state limits on youth gender-affirming care have increasingly targeted ages up to 26 — with lawmakers citing their concerns about young people’s changing bodies and development.

But opponents of such measures point to the advice of the leading medical groups on these issues. The Endocrine Society, Pediatric Endocrine Society, American Medical Association and American Psychiatric Association have all recommended gender-affirming care.

“These bills are not grounded in science. In fact, in all of these cases, the actual health care professional organizations, the experts in transgender care universally condemned these actions and their input is ignored by politicians,” said Neira, adding that Johns Hopkins All Children’s Hospital in Florida has to indefinitely suspend gender-affirming care because of state policy changes.

Medical groups have also pushed back on the argument that providing gender-affirming care would endanger the safety of a patient – another argument employed by anti-abortion groups.

Conservative advocates have successfully fought for state requirements that limit nonphysicians from providing abortions, mandate abortion providers must have hospital admitting privileges or require an ultrasound before an abortion. An ongoing lawsuit is also targeting the Food and Drug Administration’s approval of the medication abortion drug mifepristone, citing safety concerns.

The American College of Obstetricians and Gynecologists argues those restrictions are not rooted in actual safety concerns.

Major medical societies argue that denying gender-affirming care to patients, similarly, can be much more dangerous. 

A 2022 JAMA study found that transgender and nonbinary youth who received gender-affirming care had 60 percent lower odds for severe or moderate depression and 73 percent lower odds of suicidality over the course of a year. 

“Trans youth face unique challenges while growing up, and putting more roadblocks in their way to seeking affirming care only exacerbates feelings of hopelessness and exclusion,” said Sen. Jeff Merkley, D-Ore., who during the last Congress sponsored the bill Biden mentioned in his speech. “It’s disturbing to see communities and states…take steps to impose their own personal beliefs over the health and wellness needs of children and teens who already face among the highest rates of suicide of any group.”

Critics of abortion access and transgender rights have also increasingly sought to penalize physicians for providing these services. 

Texas abortion providers have been at risk through a civil enforcement abortion ban since 2021. In 2022, Texas Gov. Greg Abbott issued a directive to investigate healthcare facilities performing gender-affirming care. Alabama is similarly in litigation over its law criminalizing transgender medical care for minors.

Rep. Jennifer Wexton, D-Va. a Transgender Equality Task Force co-chair, said efforts to limit transgender health care mirror attempts “to restrict abortion freedom by inserting government into private health care decisions.” 

“It’s shameful for them to further villainize these vulnerable children,”  she said.

While violence targeting abortion providers and facilities has been documented for decades, the rising focus on transgender health has also come with increasing concerns for those providing gender-affirming care. 

In October, the American Academy of Pediatrics, American Medical Association and Children’s Hospital Association wrote to DOJ about escalating concerns related to harassment, bomb threats and coordinated disinformation campaigns. AMA said it has not received a response.

Advocates also worry about conservative arguments amplifying experiences of regret in the cases of both abortion and gender-affirming care, arguing such experiences are rare. A longitudinal study published in 2020 found that more than 95 percent of women did not regret having their abortion, even five years after the procedure.

Similarly, “the actual percentage of folks who retransition or express regret of gender affirmation is minuscule,” said Neira, adding that looking at post-surgical regret, it is between 0.4 percent and about 3.8 percent.

This report was corrected to accurately reflect Neira’s title and her comment regarding post-surgical regret.