October 4, 2023 - 10:30am

The state of Nebraska is cracking down on the medical experiment currently being run on gender-questioning youth. New regulations will require adolescents seeking medical transition to undergo therapy before and after initiating puberty blockers or cross-sex hormones, impose a seven-day waiting period before new prescriptions can be filled, and require medical providers to assess and address co-morbidities. Each step effectively pumps the brakes, slowing down a process many young patients have sped through as demand for these interventions surged. 

The Nebraska Department of Health and Human Services emphasises the need to “allow for sufficient therapeutic treatment time” to “develop a thorough understanding of a patient’s needs and determine appropriateness for treatment” that has “life-changing effects”. Surgical interventions for gender-dysphoric youth under the age of 19 are now banned in the state, under a new law that took effect the same day. 

Activists warn that delays — whether in the form of therapeutic requirements, waiting periods or blanket bans on surgical interventions for youth — put young patients at risk. But as State Senator Kathleen Kauth, who introduced the bill, said, “everyone believes they’re acting in the best interests of children; we’re just looking at it from very different sides.” 

Nebraska is just the latest state to defect from the wide-open “gender-affirming care” model that spread across the US over the past 16 years in the absence of regulation. When it comes to hormonal and surgical interventions for gender-dysphoric youth, the map of the United States now looks like a patchwork quilt: access hinges on state politics. 

Twenty-two red states — from Idaho and Montana down to Texas and Florida — have now restricted or outright banned access to puberty blockers, cross-sex hormones, and surgeries for gender-questioning patients under the age of 18. Meanwhile, blue states like California, Colorado, Illinois, Maryland, Minnesota, New Mexico, Oregon, and Washington have passed legislation to ensure access to hormonal and surgical interventions for youth, expand insurance coverage for these procedures, and shield medical providers from legal liability. 

Court challenges criss-cross the country, too, with outcomes uncertain. Just last week, the Sixth Circuit Court of Appeals cleared the states of Tennessee and Kentucky to enforce new laws banning youth medical transition, with Chief Judge Jeffrey Sutton warned that, “[u]ntil more time has passed, it is difficult to gauge the risks to children — whether by physically transitioning as a child or not — making it reasonable for accountable democracies to consider, reconsider, and if need be reconsider again the best approach to these issues.” Lawmakers and advocates on both sides of the issue appeal to the values of protecting children to support their political agendas.

The parallels with abortion restrictions and bans are clear. Republican lawmakers and trans-advocacy organisations alike are keen to draw comparisons between the two issues, with Nebraska Republicans packaging abortion restrictions together with regulations on youth medical transition, and organisations such as the American Civil Liberties Union and Planned Parenthood framing both issues as examples of “bodily autonomy” under assault.

Whether “gender-affirming care” is in fact “life-saving healthcare” is not a matter of mere assertion: either the evidence will support such a claim or refute it. Countries like Finland and Sweden that once pioneered transition for gender-dysphoric youth have recently changed course, backing away from experimental and often irreversible hormonal and surgical interventions and favouring psychotherapeutic approaches instead. But while evidence may be able to resolve conflicts abroad, political polarisation prevails in the US, where every state has now become a battlefield.

Eliza Mondegreen is a graduate student in psychiatry and the author of Writing Behavior on Substack.