In the face of anti-trans legislation sweeping the country over the past four years, California stepped up to protect trans people and in particular trans youth. In 2022, the state became the first in the nation to create a sanctuary for transgender youth seeking gender-affirming medical care.

But with President Donald Trump issuing an anti-trans executive order on his first day in office, California will need to bolster its legal efforts to protect these vulnerable youths further. Nowhere is that protection more lacking than for intersex kids at birth and in early childhood.

Intersex children are born with chromosomes, gonads, hormone function or internal or external sex organs that don’t match typical social expectations of males or females. Since the 1960s, doctors in the U.S. and around the world have routinely performed surgery to standardize the bodies of infants and children so that they are aligned with social gender norms. The protocol was developed largely on the unproven recommendations of a single psychologist and has been carried out countless times since on intersex children long before they are old enough to decide for themselves whether they want the procedures.

These irreversible nonconsensual surgeries are medically unnecessary to perform at such a young age, and as research has shown, carry a significant risk of trauma and other forms of lifelong harm, including a loss of sexual function, incontinence, chronic pain, scarring and early-onset osteoporosis. As a 2017 paper by three former U.S. surgeons general concluded, “In short, surgeries whose purpose is to ensure physical and psychological health too often lead to the opposite result.” In the waning days of the Biden administration, the U.S. Department of Health and Human Services acknowledged as much, publishing a landmark report on intersex health equity that called for an end to the practice. However, given Trump’s declaration that there are only two genders, it’s unlikely there will be any federal protections against the practice.

Once again, California and the Bay Area have a chance to lead.

The Bay Area has an important place in the history of intersex activism in the United States. This includes when Bo Laurent founded the Intersex Society of North America in Sonoma County in 1993, receiving letters from people across the country who had experienced medical trauma and wanted to get to the root of the truth about their bodies and their lives.

In 2005, the San Francisco Human Rights Commission conducted an investigation and hearing on intersex issues, concluding that “ ‘normalizing’ interventions done without the patient’s informed consent are inherent human rights abuses.” This report resonated worldwide.

At a state level, the California Legislature passed a resolution in 2018 introduced by state Sen. Scott Wiener that recognized the intersex community and the human rights violations they endure. California’s state Legislature became the first in the U.S. officially acknowledged the harm that intersex people suffered at the hands of the medical system. Yet, even a nonbinding resolution — simply recognizing these surgeries as part of the intersex community’s struggle — was an uphill battle for Wiener. Surgeons from across California traveled to Sacramento to testify against the resolution while making egregious claims, like asserting that removing a child’s clitoris helps them become a “functioning member of society.”

So what else can be done to protect these children?

Currently, no hospitals in California have publicly committed to stopping medically unnecessary nonconsensual surgeries on intersex children. It doesn’t have to be this way. Children’s hospitals in Chicago and Boston have pledged to stop the surgeries. The New York City public hospital system banned performing unnecessary or “medically premature” operations before the patient can decide — offering a model for how California hospitals, and especially those in the Bay Area, could support intersex justice.

The good news is that California has taken some positive steps. In 2017, Gov. Jerry Brown signed a bill that introduced a third option on birth certificates. It mandated that any Californian could change their legal gender without undergoing medical procedures or verification.

But if our hospitals are still carrying out these procedures on infants and children who are unable to have their say in what is done to their bodies, having a third option on a state document after a doctor has already altered body parts, doesn’t really solve the core problem.

Globally, the momentum to end these nonconsensual surgeries is surging. Over 50 evaluations by United Nations human rights treaty bodies in different countries have concluded that nonconsensual surgeries to alter the sex characteristics of people born with intersex traits are human rights violations. Parts of Australia and India, and some countries, including Malta, Greece and Spain have passed bans on nonconsensual surgeries, while the U.N. Human Rights Council passed its first resolution on the issue last year. A growing list of medical associations and experts have spoken in favor of ending nonconsensual surgeries.

The U.S. intersex rights movement has made enormous progress, from a grassroots start in the Bay Area to influencing federal policy. California has protected marginalized youth in many ways. But until the hospitals end these harmful practices on intersex children, the fight is far from over.