Understanding the Legal Landscape
Across the U.S., laws governing gender-affirming medical care for minors have shifted rapidly. In many states, providers are prohibited from initiating puberty blockers, hormone therapy, or gender-affirming surgeries for youth under 18. However, in most states, providers can still offer essential support.
What You Can Do in Most Restrictive States
Even in states with treatment bans, providers can typically:
Comprehensive Medical Support
- Provide primary and preventive care to transgender and gender-diverse youth
- Order and interpret lab tests to monitor both general health and impact of hormones
- Offer emergency and inpatient care, including for youth receiving gender-affirming hormones prescribed elsewhere
- Refer families to affirming mental health professionals (unless specifically prohibited)
- Maintain affirming provider-patient relationships grounded in trust and support
Family Guidance and Education
- Educate families about gender diversity and youth development
- Offer psychosocial support and referrals to national support organizations
- Guide families to medical congruence options in other states (unless specifically prohibited)
Documentation and Continuity
- Maintain thorough and accurate records of clinical assessments and decisions
- Provide general medical assessments
- Monitor treatment prescribed by out-of-state providers (only Indiana and possibly Florida raise issues around coordination or communication)
What You Cannot Do in Most Restrictive States
In states with standard treatment bans, providers generally may not:
- Prescribe puberty blockers (GnRH analogues) to minors
- Prescribe gender-affirming hormones (testosterone, estradiol) to minors
- Perform or refer directly for gender-affirming surgeries for minors
- Submit insurance claims for services that are restricted by law
- Circumvent these bans through direct billing or alternative payment arrangements
Violations may carry significant professional risks, including license suspension or revocation, civil liability, and under certain statutes, criminal penalties.
Special Considerations: States with Expanded Provider Restrictions
Seven states have passed laws that go beyond treatment bans, targeting provider communication, referrals, and care coordination:
Florida
- Referral bans: Cannot refer patients (including out-of-state) for gender-affirming care
- Attestation requirements: Facilities must confirm they do not refer for gender-affirming treatment
- Penalties: License revocation for facilities, criminal penalties for individual violations
New Hampshire
- Referral bans: Cannot refer for any gender-affirming treatment as of 2026
- Counseling restrictions: Prohibits supporting gender-affirming care in any form (effective 2026)
- Penalties: Licensing discipline and civil litigation exposure
Indiana
- Care coordination ban: Prohibits communication with out-of-state providers about gender-affirming care
- Medical record sharing restrictions
- Penalties: Licensing board sanctions
Missouri
- Referral restrictions: In-state referrals banned, out-of-state legality unclear
- Legal risks: 15-year extended malpractice liability for care provided
- Penalties: Civil and licensing exposure
Tennessee
- Transportation restrictions: Prohibits aiding travel across state lines without parental consent
- Penalties: Civil fines; does not apply when a parent or guardian initiates care
Arkansas (Currently Blocked)
- Planned referral ban: Would bar providers from recommending gender-affirming care elsewhere
- Status: Law is currently blocked by federal court
Arizona
- Ambiguity: Legal language around referrals was removed, but boards may treat referrals as unprofessional conduct
- Currently applies only to surgery, not hormones or blockers
- Penalties: Licensing discipline possible
Legal Protections for Out-of-State Providers
Providers in 18 states and the District of Columbia now benefit from shield laws protecting those who provide or assist in gender-affirming care, even across state lines. These laws offer legal safeguards against subpoenas, disciplinary actions, and civil liability from states that ban affirming care.
States with enacted shield laws: California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Rhode Island, Vermont, Washington, Maine, District of Columbia
Note: Laws vary by state. Some shield laws protect only abortion providers, while others explicitly include gender-affirming care. Always verify the scope of protections with legal counsel or state-level policy experts before relying on these laws for cross-border coordination.
Recommendations for Navigating Complex Legal Environments
- Know your state’s laws: Use reliable legal summaries and consult your licensing board
- Document with care: Keep detailed records of clinical decisions, care refusals, and communications
- Communicate transparently: Let families know what support you can offer within legal limits
- Protect yourself: Confirm malpractice insurance covers evolving liabilities related to gender-affirming care
- Stay informed: Laws are changing quickly. Subscribe to legal updates from reputable medical and legal organizations