Doctors and advocates say efforts to ban gender-affirming care and the often inaccurate language lawmakers use to do it exploits most Americans’ relative unfamiliarity with transgender people to push a political agenda.

As those efforts have grown — nearly exclusively led by Republicans — they have superseded both abortion rights and same-sex marriage as the go-to social issue among conservatives in the lead-up to the November elections.

The attacks have had an impact. Kellan Baker, the executive director of Whitman-Walker Institute, a D.C.-based health clinic specializing in LGBTQ+ health care, said that basing these attacks on falsehoods helps craft the narrative of transgender people as a “boogeyman” in order to scare people.

“There’s less than 1 percent of the U.S. population that is transgender, which means that many people don’t know a transgender person personally, or even if they do, they maybe don’t know that much about what medical care for transgender people looks like,” Baker said.

“And so it’s very easy to project this kind of false image of a boogeyman, to have this kind of nightmare scenario that’s not real.”

Most major medical and mental health associations in the United States, including the American Medical Association, American Academy of Pediatrics and the American Psychiatric Association, say gender-affirming care, which includes a wide range of services including hormone therapy and surgical procedures, is medically necessary.

“This is not just kind of made-up care, or just, we’re kind of freestyling it,” said Terrence Weeden, a staff adolescent physician at Whitman-Walker. “This is supported by multiple organizations, professional organizations, who are providing guidelines.”

In April 2021, the American Medical Association sent a letter to the National Governors Association urging its members to oppose laws that limit choices for health care by families and providers related to gender-affirming care after Arkansas passed a law that would prohibit physicians from providing gender-affirming care for minors.

“We believe it is inappropriate and harmful for any state to legislatively dictate that certain transition-related services are never appropriate and limit the range of options physicians and families may consider when making decisions for pediatric patients,” the letter said.

The bill was vetoed by Arkansas Gov. Asa Hutchinson, a Republican, who called it a “vast government overreach.” The Arkansas State Legislature successfully voted to override his veto. A federal district judge in Arkansas struck down the ban in June 2023 as unconstitutional. It was then appealed to the U.S. Court of Appeals for the 8th Circuit, where judges heard arguments for the case in April. The case is ongoing.

Efforts to ban gender-affirming care in state legislatures have a ripple effect in Congress.

“Mutilating children is bad — that’s generally a good stance to take,” said Rep. Daniel Crenshaw, R-Texas.

Crenshaw, who does not have a background in medicine, said doctors who practice gender-affirming care are performing “pseudoscience” and recommended that doctors should “read a book.”

Gillian Branstetter, a communications strategist for the American Civil Liberties Union’s LGBTQ and HIV project, said lawmakers like Crenshaw base their attacks on a concern for children’s well-being to get support for their views.

“That’s all designed to inflame people’s emotions,” Branstetter said. “Because they know people are generally concerned for children, and they want to use the mantle of protecting children to go after trans kids more broadly.”

The focus on rhetoric like Crenshaw’s is part of an effort to discredit health care that has been established as safe and to manufacture doubt, Branstetter said. Part of that, she said, is to use as many lies as possible to see what sticks with people who may have never met a trans person like Branstetter.

“I don’t think the goal is getting people to believe one lie. It’s throwing out as many lies as possible in order to make people believe in nothing so that when they hear from transgender people ourselves or the parents of transgender youth or medical experts or medical organizations, that they aren’t believed either,” she said.

Medicine misconceptions

Though attacks on gender-affirming care have increased over the past few years, many of the medical procedures under the umbrella of gender-affirming care are not new.

Puberty blockers were first approved by the FDA in 1993. Originally approved to temporarily delay puberty in children who were going through it too early, they block the release of hormones leading to puberty-related changes in the body. Such treatments are also reversible — a child who was taking them would be able to eventually go through puberty if they stopped taking them, Weeden said.

“Essentially, puberty is paused. And basically, that allows that youth or that child to kind of explore their gender, explore if they really want to pursue hormones or not. And so puberty-pausing medications are reversible,” Weeden said.

Weeden said that one misconception people have about gender-affirming care is how long it takes for people to start certain aspects of care, such as puberty blockers or hormone replacement therapy.

Unlike other medications, the process isn’t as simple as getting a prescription after one appointment — people will see multiple providers, including a behavioral health specialist, before they start the medication. The process, Weeden said, can take weeks to months.

“It is a multidisciplinary approach in that you have input from behavioral health specialists and clinicians, psychiatrists, sometimes an endocrinologist . . . A lot of different specialties come together in agreement to support this view in their transition,” he said.

In the case of minors, all aspects of gender-affirming care, from puberty blockers to hormone replacement therapy, are done only with parental consent, Weeden said.

But for Sen. Ted Cruz, R-Texas, the guidance from major medical organizations and from physicians like Weeden is insignificant.

“​​It is never medically necessary to sterilize or castrate a child. And it is only adults in pursuit of a political agenda who do that to little boys and little girls, even though an eight-year-old lacks the emotional maturity to make lifelong decisions and give up the ability to be a mother or father because of peer pressure in the moment,” Cruz said.

“My opposition has been really on the minors side of it,” said Sen. James Lankford, R-Okla.

Many Republicans, like Cruz, often point to surgery for youth as a driving force behind their objections, portraying it as a common procedure for trans youth.

But most transgender youth who receive gender-affirming care do not have surgery as minors. A study published in 2023 in JAMA Network Open tracked more than 48,000 patients who had operations in hospitals and outpatient surgery centers. It found that, of those who had gender-affirming surgery from 2016-20, fewer than 8 percent — 3,678 — were aged 12-18. Surgeries in younger patients were primarily breast and chest procedures, while genital surgical procedures were more common in older patients.

Such procedures for youth are rare, and when they do happen, happen only with the consent of parents and in consultation with multiple other health providers, Weeden said.

“This is an informed-consent process with consent from parents and support from providers and professionals. So we cannot do any of this without the consent from their parents,” Weeden said.

Legislation

Seventy-five anti-trans bills have been introduced during this Congress, including bills that would prohibit trans people from serving in the military and a bill that would make it a felony for doctors to perform gender-affirming care on minors, according to the Trans Legislation Tracker, an independent database tracking bills affecting transgender people across the United States.

At the state level, 638 bills have been introduced across 43 states in 2024, with 45 of them having passed. Of those introduced, 466 failed. The remainder have yet to move.

Although there has yet to be a federal law restricting access to gender-affirming care, 25 states have laws that limit youth access to gender-affirming care, according to KFF, a health care think tank.

Restrictions on gender-affirming care have made their way into a series of must-pass appropriations bills.

They’ve also been attached to must-pass authorizations: An amendment to the fiscal 2025 National Defense Authorization Act that would prohibit TRICARE from covering and the Defense Department from furnishing gender transition surgeries and gender hormone treatments for individuals who identify as transgender. The House adopted the amendment June 13 by a vote of 213-206. The bill ultimately passed the House by a vote of 217-199.

The Senate Armed Services Committee approved its version of the NDAA last month, which also included an amendment to prohibit the Defense Department from providing gender-affirming surgeries to transgender servicemembers or insurance coverage for any gender-affirming medical care for transgender youth whose parents are serving in the military.

The bill would likely not pass the full Senate with such an amendment, let alone get signed into law by President Joe Biden.

But for Branstetter and others, that doesn’t make the existence of these bills any less frightening.

“Part of the effort is again dehumanizing trans people from a kind of person into a toxic influence that can be stamped out,” Branstetter said.

Ariel Cohen contributed to this report.