The Associated Press

North Dakota’s Republican Gov. Doug Burgum signed a bill into law that restricts transgender health care in the state, immediately making it a crime to give gender-affirming care to people younger than 18.

Gender-affirming care for minors has been available in the U.S. for more than a decade and is endorsed by major medical associations, but it has increasingly come under attack in many conservative legislatures, including North Dakota’s, where lawmakers have passed at least three bills targeting trans people this year.

The measure that Burgum signed Wednesday received veto-proof support from GOP lawmakers — though some Republicans did vote against it, alongside all Democrats.

In a statement released Thursday morning, Burgum said the law is “aimed at protecting children from the life-altering ramifications of gender reassignment surgeries” but he added that medical professionals have testified these surgeries have not been and are not being performed on minors in North Dakota.

He said the law still allows medication treatment for early onset puberty and other rare circumstances with parental consent, and minors currently receiving gender-affirming care will still be able to receive treatment.

“Going forward, thoughtful debate around these complex medical policies should demonstrate compassion and understanding for all North Dakota youth and their families,” he said.

The new law takes immediate effect and allows prosecutors to charge a health care provider with a felony — up to 10 years in prison and $20,000 in fines — for performing sex reassignment surgery on a minor.

It also enables prosecutors to charge a provider with a misdemeanor — up to 360 days in prison and $3,000 in fines — for giving gender-affirming medication, like puberty blockers or hormone therapy, to a trans child.

The American Civil Liberties Union of North Dakota denounced the new law as “a vast government overreach that undermines the fundamental rights of parents” and that violates constitutional guarantees of equal protection and due process by singling out gender-affirming care for prohibition.

“By signing this bill into law, Gov. Burgum has put the government in charge of making vital decisions traditionally reserved for parents in North Dakota,” Cody Schuler, the group’s advocacy manager, said in a statement. “This ban won’t stop North Dakotans from being trans, but it will deny them critical support that helps struggling transgender youth grow up to become thriving transgender adults.”

Earlier this month, Burgum also signed a transgender athlete ban into law after it similarly passed the House and Senate with veto-proof majorities. In 2021, Burgum vetoed a bill that would have imposed a transgender athlete ban at that time, but House and Senate lawmakers did not have enough votes back then to override his veto.

North Dakota joins at least 13 other states that have enacted laws restricting or banning gender-affirming care for minors.

Republican lawmakers across the country have advanced hundreds of measures aimed at nearly every facet of trans existence this year.

That includes bans on gender-affirming medical care for minors, restrictions on the types of restrooms transgender people can use, measures restricting classroom instruction on sexual orientation and gender identity, and bills that would out transgender students who want teachers to address them by the pronouns they use.

The Food and Drug Administration approved puberty blockers 30 years ago to treat children with precocious puberty — a condition that causes sexual development to begin much earlier than usual. Sex hormones — synthetic forms of estrogen and testosterone — were approved decades ago to treat hormone disorders or as birth control pills.

The FDA has not approved the medications specifically to treat gender-questioning youth, but they have been used for many years for that purpose “off label,” a common and accepted practice for many medical conditions. Doctors who treat transgender patients say those decades of use are proof the treatments are not experimental.

Research has shown that transgender youths and adults can be prone to suicidal behavior when forced to live as the sex they were assigned at birth. And critics of legislation to restrict gender-affirming care for children say it’s an attempt by conservatives to motivate their voting base.

Proponents of the measure have raised concerns about children changing their minds. Yet the evidence suggests detransitioning is not as common as opponents of transgender medical treatment for youth contend, though few studies exist and they have their weaknesses.

Missouri’s attorney general announced new restrictions Thursday on gender-affirming care for adults in addition to minors in a move that is believed to be a first nationally and has advocacy groups threatening to sue.

Attorney General Andrew Bailey announced plans to restrict health care for transgender people weeks ago, when protesters rallied at the Capitol to urge lawmakers to pass a law banning puberty blockers, hormones and surgeries for children. But the discussion was focused on minors, not adults.

Missouri Attorney General spokeswoman Madeline Sieren clarified in a statement later in the day that adults also would be covered.

“We have serious concerns about how children are being treated throughout the state, but we believe everyone is entitled to evidence-based medicine and adequate mental health care,” Sieren said.

The rule, which incudes a required 18 months of therapy before receiving gender-affirming health care, is set to take effect April 27 and expire next February.

The ACLU and Lambda Legal said in a joint statement that they would “take any necessary legal action” and urged those affected to call.

“The Attorney General’s so-called emergency rule is based on distorted, misleading, and debunked claims and ignores the overwhelming body of scientific and medical evidence supporting this care,” the statement said.

Robert Fischer, the spokesman for the LGBTQ rights groups PROMO, said he was not aware of similar restrictions elsewhere.

“He’s essentially attacking the entire trans community at this point,” Fischer said of Bailey. “It’s no longer just about children.”

The National Center for Transgender Equality called the order “deeply wrong” in a tweet, adding that “trans people of all ages across the state of Missouri deserve access to health care.”

The restrictions are in response to a former employee’s allegations of mistreatment at a transgender youth clinic in St. Louis run by Washington University. Bailey is investigating the center.

“My office is stepping up to protect children throughout the state while we investigate the allegations and how they are harming children,” Bailey said in a statement.

University spokespeople didn’t immediately respond to phone or email messages from The Associated Press seeking comment.

Moving forward, doctors who provide gender-affirming health care must first provide them a lengthy list of potential negative side effects and information warning against those treatments, according to a copy of the rule released Thursday.

Health care providers will need to ensure “any psychiatric symptoms from existing mental health comorbidities of the patient have been treated and resolved” before providing gender-affirming treatments under the new rule. Physicians also must screen patients for social media addiction, autism and signs of “social contagion with respect to the patient’s gender identity.”

The FDA approved puberty blockers 30 years ago to treat children with precocious puberty — a condition that causes sexual development to begin much earlier than usual. Sex hormones — synthetic forms of estrogen and testosterone — were approved decades ago to treat hormone disorders or as birth control pills.

The FDA has not approved the medications specifically to treat gender-questioning youth, but they have been used for many years for that purpose “off label,” a common and accepted practice for many medical conditions. Doctors who treat transgender patients say those decades of use are proof the treatments are not experimental.

Critics have raise concerns about children changing their minds. Yet the evidence suggests detransitioning is not as common as opponents of transgender medical treatment for youth contend, though few studies exist and they have their weaknesses.

Bailey’s rule was released the same day Missouri’s Republican-led House voted to ban access to transgender-related health care for minors.

The House voted 103-52 along mostly party lines in favor of the ban, although the bill’s passage seems uncertain in the Senate.

The House proposal is stricter than what was passed by the GOP-led Senate, where Democrats have more influence through the use of stall tactics.

Senators compromised to exempt care for minors whose treatment is already underway. The Senate bill also would expire after four years.

The House version includes no exceptions for current treatments and would remain in effect indefinitely.

Republican Senate leaders said it’s unlikely that the House version will make it through the Senate.

“We’ve already passed legislation on this issue out of the Senate,” Senate President Pro Tem Caleb Rowden said. “We would expect the House to appreciate how hard and difficult it was and to take up our bill and pass it.”

Both the House and Senate proposals would ban inmates and prisoners from accessing gender-affirming surgeries and would end coverage of any gender-affirming treatments for Missouri patients on Medicaid, the federal health insurance program.

The Human Rights Campaign condemned the legislation in a statement, describing gender-affirming care as medically necessary.

At least 13 states have now enacted laws restricting or banning gender-affirming care for minors: Alabama, Arkansas, Arizona, Georgia, Idaho, Indiana, Iowa, Kentucky, Mississippi, Tennessee, Utah, South Dakota and West Virginia. Bills are awaiting action from governors in Kansas, Montana and North Dakota. Federal judges have blocked enforcement of laws in Alabama and Arkansas, and nearly two dozen states are considering bills this year to restrict or ban care.

House debate on the bill became emotional as some Democrats argued the ban on health care will hurt transgender children.

“You are erasing my grandchild,” said St. Louis Democratic Rep. Barbara Phifer, whose grandson is transgender.

Republican sponsor Rep. Brad Hudson, of Cape Fair, criticized Democrats for threatening to end political partnerships and friendships with Republicans over the bill.

Hudson said his bill “seeks to protect kids” and that it’s unfair that Democrats are describing it as hateful towards transgender children.

“A yes vote is a vote to protect kids from sex-change drugs and surgeries,” Hudson said.

Associated Press

Kentucky’s Democratic governor issued an election-year veto Friday of a sweeping Republican bill aimed at regulating the lives of transgender youths that includes banning access to gender-affirming health care and restricting the bathrooms they can use.

The bill also bans discussion of sexual orientation and gender identity in schools and allows teachers to refuse to refer to transgender students by the pronouns they use. It easily passed the GOP-dominated legislature with veto-proof margins, and lawmakers will reconvene next week for the final two days of this year’s session, when they could vote to override the veto.

Gov. Andy Beshear said in a written veto message that the bill allows “too much government interference in personal healthcare issues and rips away the freedom of parents to make medical decisions for their children.”

In his one-page message, he warned that the bill’s repercussions would include an increase in youth suicides. The governor said, “My faith teaches me that all children are children of God and Senate Bill 150 will endanger the children of Kentucky.”

Beshear told reporters later Friday that transgender children and their parents were among the Kentuckians who contacted his office as he reviewed the legislation.

“I heard from children that believe this bill is picking on them, and asking — in many ways — why?” the governor said. “I told them that I was going to show them that there is at least one person in Frankfort that cares for all of our children in the commonwealth, no matter what.”

Beshear’s veto comes as he seeks re-election to a second term this year in Republican-trending Kentucky, and his veto could reverberate through the November election.

Republicans quickly pounced on the governor’s veto to try to portray him as out of touch with most Kentuckians on the culture wars issue.

“Andy Beshear thinks it’s okay for children to have access to life-altering sex change surgery and drugs before they turn 18,” state Republican Party spokesperson Sean Southard said in a statement. “Today, he revealed how radical he truly is.”

Related stories

• Georgia law will ban most transgender care for kids under 18
• Arkansas restricts school bathroom use by transgender people
• Wyoming bans transgender youth from girls’ sports teams

The legislation in Kentucky is part of a national movement, with state lawmakers approving extensive measures that restrict the rights of LGBTQ+ people this year, from bills targeting trans athletes and drag performers to measures limiting gender-affirming care.

In Kentucky, the expanded version that reached Beshear’s desk was rushed through both legislative chambers in a matter of hours on March 16 before lawmakers began an extended break. The fast-track work enabled lawmakers to retain their ability to override the governor’s veto. The action triggered outrage and tears among opponents unable to stop the legislation.

The bill’s supporters say they are trying to protect children from undertaking gender-affirming treatments that they might regret as adults. Research shows such regret is rare.

The repackaged measure would ban gender-affirming care for transgender minors. It would outlaw gender reassignment surgery for anyone under 18, as well as the use of puberty blockers and hormones, and inpatient and outpatient gender-affirming hospital services.

Doctors would have to set a timeline to “detransition” children already taking puberty blockers or undergoing hormone therapy. They could continue offering care as they taper a minor’s treatments, if removing them from the treatment immediately could harm the child.

Transgender medical treatments have long been available in the United States and are endorsed by major medical associations.

“The American Medical Association reports that receipt of care dramatically reduces the rates of suicide attempts, decreases feelings of depression and anxiety and reduces substance abuse,” Beshear said in his veto message.

The bill would not allow schools to discuss sexual orientation or gender identity with students of any age.

Another key provision would require school districts to devise bathroom policies that, “at a minimum,” would not allow transgender children to use the bathroom aligned with their gender identities.

It also would allow teachers to refuse to refer to transgender students by the pronouns they use and would require schools to notify parents when lessons related to human sexuality are going to be taught.

Beshear said in his veto message that the bill would turn educators and administrators into “investigators that must listen in on student conversations and then knock on doors to confront and question parents and families about how students behave and/or refer to themselves or others.”

David Walls, executive director of The Family Foundation, condemned the veto, saying the bill seeks to protect children and their parents from “radical, politicized ideologies.” He said the bill would result in “setting policy in alignment with the truth that every child is created as a biological male or female and deserves to be loved, treated with dignity, and accepted for who they really are.”

After the bill passed the legislature, the American Civil Liberties Union of Kentucky warned that it “stands ready” to challenge the measure in court if it becomes law.

Arkansas Gov. Sarah Huckabee Sanders on Tuesday signed a law prohibiting transgender people at public schools from using the restroom that matches their gender identity, the first of several states expected to enact such bans this year amid a flood of bills nationwide targeting the trans community.

The bill signed by the Republican governor makes Arkansas the fourth state to place such restrictions at public schools, and it comes as bills in Idaho and Iowa also await their governor’s signature. And it might be followed by an even stricter Arkansas bill criminalizing transgender adults using public restrooms that match their gender identity.

Arkansas’ law, which won’t take effect until later this summer, applies to multi-person restrooms and locker rooms at public schools and charter schools serving prekindergarten through 12th grade. The majority-Republican Legislature gave final approval to the bill last week.

“The Governor has said she will sign laws that focus on protecting and educating our kids, not indoctrinating them and believes our schools are no place for the radical left’s woke agenda,” Alexa Henning, Sanders’ spokesperson, said in a statement. “Arkansas isn’t going to rewrite the rules of biology just to please a handful of far-left advocates.”

Similar laws have been enacted in Alabama, Oklahoma and Tennessee, although lawsuits have been filed challenging the Oklahoma and Tennessee restrictions.

Proposals to restrict transgender people using the restroom of their choice have seen a resurgence this year, six years after North Carolina repealed its bathroom law in the wake of widespread protests and boycotts. More than two dozen bathroom bills have been filed in 17 states, according to the Human Rights Campaign.

“They’re singling out transgender people for no other reason than dislike, disapproval and misunderstanding of who transgender youth are,” said Paul Castillo, senior counsel and students’ rights strategist for Lambda Legal. “And the entire school population suffers as a result of these types of bills, particularly schools and teachers and administrators who are dealing with real problems and need to focus on creating a welcome environment for every student.”

The proposals are among a record number of bills filed to restrict the rights of transgender people by limiting or banning gender-affirming care for minors, banning transgender girls from school sports and restricting drag shows. Transgender people have also faced increasingly hostile rhetoric at statehouses.

Another bill pending in Arkansas goes even further than the North Carolina law by imposing criminal penalties. That proposal would allow someone to be charged with misdemeanor sexual indecency with a child if they use a public restroom or changing room of the opposite sex when a minor is present.

“It’s a flagrant message from them that they refuse to respect (transgender people’s) rights and humanity, to respect Arkansans’ rights and humanity,” said Holly Dickson, executive director of the American Civil Liberties Union of Arkansas.

The new Arkansas law requires schools to provide reasonable accommodations, including single-person restrooms. Superintendents, principals and teachers who violate the prohibition could face fines of at least $1,000 from a state panel, and parents could also file private lawsuits to enforce the measure.

“Each child in our schools has a right to privacy and to feel safe and to feel comfortable in the bathroom they need to go to,” Republican Rep. Mary Bentley, the bill’s sponsor, told lawmakers earlier this year.

But Clayton Crockett, the father of a transgender child, described to lawmakers earlier this year how a similar policy adopted at his daughter’s school made her feel further marginalized.

“She feels targeted, she feels discriminated against, she feels bullied, she feels singled out,” Crockett said at a House panel hearing on the bill in January.

Opponents have also complained the legislation doesn’t provide funding for schools that may need to build single-person restrooms to provide reasonable accommodations.

At least two federal appeals courts have upheld transgender students’ rights to use the bathroom corresponding with their gender identity. Supporters of the bill, however, have cited a federal appeals court ruling upholding a similar policy at a Florida school district last year.

The Arkansas measure won’t take effect until 90 days after the Legislature adjourns this year’s session, which isn’t expected to happen until next month at the earliest.

Sanders signed the bill a week after she approved legislation making it easier to sue providers of gender-affirming care to minors. That law, which also doesn’t take effect until this summer, is an effort to effectively reinstate a ban on such care for minors that’s been blocked by a federal judge.

Sanders earlier this month also signed a wide-ranging education bill that prohibits classroom instruction on gender identity and sexual orientation before 5th grade. The restriction is similar to a Florida measure that critics have called the “Don’t Say Gay” law.

Arkansas Gov. Sarah Huckabee Sanders has signed legislation making it easier to sue providers of gender-affirming care for children, a move that could effectively reinstate a blocked ban on such care.

Sanders on Monday signed the new law, which won’t take effect until this summer. It would allow anyone who received gender-affirming care as a minor to file a malpractice lawsuit against their doctor for up to 15 years after they turn 18. Under current Arkansas law, medical malpractice claims must be filed within two years of an injury.

Legal experts have said the change could close access to gender-affirming care for children by making it nearly impossible for providers to get malpractice insurance.

“Arkansas infamously passed the first law in the nation to try to ban gender affirming care for trans youth and after hearing extensive evidence, the courts have blocked that ban,” Holly Dickson, executive director of the American Civil Liberties Union of Arkansas, said in a statement. “This bill is an effort to achieve indirectly what the Constitution prohibits the state from doing directly.”

The new law is among a growing number of bills targeting transgender people, who have faced increasingly hostile rhetoric at statehouses. At least 175 bills targeting trans people have been introduced in statehouses so far this year, the most in a single year, according to the Human Rights Campaign.

The bill was signed as a federal judge is considering whether to strike down a 2021 Arkansas law that would prohibit doctors from providing gender-affirming hormone therapy or puberty blockers to anyone under 18 — or referring them to other doctors who can provide that care. No gender-affirming surgery is performed on minors in the state.

Republican Sen. Gary Stubblefield, who sponsored the malpractice law, said he didn’t know if the measure would face a similar court challenge.

“Anything can create a court challenge in the world we live in today,” Stubblefield said. “I know we did what we thought was best for our children.”

U.S. District Judge Jay Moody temporarily blocked the state’s ban on gender-affirming care for minors in 2021. Arkansas was the first state to enact such a ban, and several states have approved similar restrictions. A ban in Alabama has also been blocked by a federal judge.

Opponents of such treatments argue that minors are too young to make decisions about their futures. But every major medical group, including the American Medical Association, supports gender-affirming care for youths and has opposed the bans.

The malpractice legislation includes a “safe harbor” provision that would give doctors a defense against malpractice lawsuits over providing gender-affirming care for children, but only if they follow restrictions that experts have said are inconsistent with the standard of care for the treatments.

The new law won’t take effect until 90 days after the Legislature adjourns this year’s session, which isn’t expected to happen until next month at the earliest.

The bill is among several targeting transgender youth that have been proposed in Arkansas this year.

Others include legislation that would criminalize transgender adults using the bathroom that corresponds with their gender identity. The bill goes even further than a bathroom bill North Carolina repealed following widespread boycotts.

Dickson urged Sanders to hear from trans youth and those who care from them before signing any more bills affecting the LGBTQ community.

Former Vice President Mike Pence is stepping up his outreach in Iowa ahead of a possible 2024 presidential campaign by rallying conservatives against transgender-affirming policies in schools, like one adopted in an eastern Iowa district last year.

The effort by Advancing American Freedom, a group formed by Pence in 2021 and financed by his supporters, will include digital ads, rallies, canvassing and perhaps radio and television spots. It comes as a federal court in Minnesota is scheduled next week to hear a case brought by a group representing parents of students in Linn-Mar Community School District outside Cedar Rapids.

“The strength of our nation is tied to the strength of our families, and we cannot stand idly by as the radical left attempts to indoctrinate our children behind parents’ backs,” Pence said in a statement provided to The Associated Press. “Advancing American Freedom will not rest until parental rights are restored in Iowa and across the nation.”

The Linn-Mar board last year adopted a policy allowing students to request a gender support plan to begin socially transitioning at school and without the permission of their parents. The group representing the parents is suing to overturn the policy.

The planned budget for the effort is more than $1 million, and the push is expected to last several months, said a Pence aide, who spoke on condition of anonymity ahead of a formal announcement later Thursday.

The moves by the outside group — separate from any potential Pence candidacy — comes as school policy, notably involving gender identification and sexual orientation, has become an early focus of 2024 Republican presidential prospects.

The issue is particularly relevant in Iowa, given both the court case and the Republican-controlled Legislature advancing legislation barring schools from supporting a student’s social change in gender identity.