When Dylan Brandt looks back on the time before he started receiving gender-affirming care, he remembers feeling trapped "in a pretty bad place." He wasn't comfortable leaving the house, and he struggled with anxiety and depression.
It was right around his 15th birthday that Brandt began hormone therapy. He says the treatment was "lifesaving."
"When I started these hormones, not only did it change my physical appearance, but it changed my mind," Brandt, now 17, says. "I felt better because I was looking better. I felt free. I felt happy."
Today, that joy is overshadowed by fear that his access to treatment may soon disappear because of a 2021 law passed in Arkansas, Brandt's home state, that bans gender-affirming care for transgender youth like himself. Brandt is now part of an ACLU lawsuit seeking to overturn the ban, and says that if the law is upheld, he and his family would have to leave the state.
"We wouldn't have any other choice, because this isn't something I can live without," says Brandt.
The Arkansas ban is part of a wave of new state laws that has begun to radically reshape life for trans youth across the nation, bringing restrictions on everything from health care to how their gender identity is treated at school.
An NPR analysis of this fast-changing landscape found that over the past two years, state lawmakers introduced at least 306 bills targeting trans people, more than in any previous period. A majority of this legislation, 86%, focuses on trans youth.
While not every proposal has succeeded — about 15% of the bills have become law — the surge of legislative activity reflects what many advocates see as an increasingly hostile environment for LGBTQ rights in statehouses across the country and even some corners of Congress.
Some of the new laws have been temporarily blocked by the courts. But legal challenges have done little to slow the pace of new proposals, according to Katie Eyer, a professor at Rutgers Law School. It's an echo, she says, of the period after Brown v. Board of Education, when the U.S. Supreme Court struck down segregation in schools, but many states kept trying to pass laws to obstruct the ruling.
"This phenomenon of states just ... churning out legislation as it's struck down is one that has a long history in civil rights," says Eyer. "And it can really stymie efforts for people to actually experience what the courts have said should be their constitutional rights."
It's also a phenomenon that advocates for the trans community fear will have disastrous consequences for trans youth in particular. A January poll from the Trevor Project, an organization that provides crisis support for the LGBTQ community, found that 85% of trans and nonbinary youth said their mental health was negatively affected by these laws. A subsequent poll found that more than half of trans and nonbinary youth "seriously considered" suicide in the past year.
"Regardless of if these bills pass ... it is already having a negative impact for LGBTQ youth generally," says Sam Ames, director of advocacy and government affairs at the Trevor Project. For many, Ames says, "we are talking about life and death."
More than half the states have sought to restrict gender-affirming health care
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For some trans youth, proposed restrictions would make it significantly harder to access gender-affirming health care. For others, it would make it virtually impossible.
In four states — Alabama, Arkansas, Arizona and Tennessee — lawmakers have enacted either a partial or total ban on access to gender-affirming care, though in Alabama and Arkansas the laws are not currently in effect due to court injunctions. At least 20 others have tried.
Many of these proposals have sought to restrict anyone under the age of 18 from care that includes puberty blockers, hormone replacement therapy or transition-related surgery. In some of those states, health care providers now face the threat of jail time for offering gender-affirming care.
Restrictions also have come by way of executive order or regulation rather than legislation. Earlier this year, Texas Gov. Greg Abbott directed the state's child welfare agency to investigate parents and health care providers who give gender-affirming care to trans youth, characterizing those actions as child abuse. The order continues to be challenged in court. And earlier this month, Florida's State Medical Board effectively banned doctors from providing gender-affirming care for new patients under the age of 18.
Advocates fear the overall fallout could be dramatic. An estimated 300,000 American youth ages 13 to 17 identify as transgender, and according to a March study by the Williams Institute at the UCLA School of Law, at least 53,800 were at risk of losing gender-affirming medical care.
Many of the proposed laws have come despite what critics see as a drumbeat of misinformation about gender-affirming care. Trans-rights advocates say some bills have sought to ban procedures that are rarely available to young patients. For example, a Tennessee law blocks health care providers from providing hormone treatments to prepubescent minors, even though the World Professional Association for Transgender Health only recommends treatment once a minor has entered puberty.
"One of the really concerning trends that we see is that these bills are becoming more extreme over time," says Alex Petrovnia, president of the Trans Formations Project, an advocacy group. "Frankly, I really do think that the end goal is to ban trans-affirming medical care, period, ... which should scare people a lot more than it does because access to gender-affirming care is fundamentally an issue of bodily autonomy."
Schools have emerged as the front line for anti-trans legislation
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Legislation targeting the trans community isn't new. In 2016, North Carolina sparked nationwide outrage with a so-called "bathroom bill" that sought to block trans people from using public restrooms that don't correspond with the gender that appears on their birth certificate. The backlash would later push the state to reverse course.
Six years later, the environment has changed considerably. Bathroom bills are back, and this time they are taking aim at school restrooms and locker rooms. At least nine states have moved to block trans students from using restrooms that don't correspond with the sex assigned to them at birth. Three of them — Alabama, Oklahoma and Tennessee — have succeeded. But unlike the public backlash that pushed North Carolina to backpedal, this most recent crop of legislation has moved through state capitols with far less controversy.
The focus on trans students underscores the extent to which schools, perhaps more than any other area of American life, have emerged as the front line for restrictions on trans rights. Of the more than 126 bills introduced so far in 2022, some 63% have centered on schooling.
Most of these bills would prevent transgender female students from participating in female sports. The bills largely draw inspiration from Idaho, which in 2020 became the first state in the nation to ban transgender women and girls from kindergarten through college from competing on teams that align with their gender identity. That ban is currently blocked by a court injunction. Nevertheless, since Idaho's ban, 18 states have followed suit with their own laws.
Supporters of these bills, like Republican state Rep. Scott Cepicky of Tennessee, say their efforts have more to do with fairness in competition than with gender identity. Earlier this year, Cepicky sponsored legislation that says student-athletes can only compete in sports under the gender they were assigned at birth. The bill was signed by Gov. Bill Lee in May.
"The whole premise behind the bill was to separate out the politics from this, because sports is about competition," Cepicky says. "It's about everybody having an equal opportunity on the playing field to compete. And we want to make sure that females were competing against females and males were competing against males on the athletic fields so that the opportunities for competition were balanced, the opportunities for scholarships and awards were balanced."
Critics, however, see a solution in search of a problem. They point to a 2021 investigation by The Associated Press that found that most Republican sponsors of bills seeking to ban transgender girls from competing on girls' sports teams were unable to cite a single example from their state or region where the lack of any such ban caused a problem.
Similarly, a growing number of states are pursuing parental disclosure laws. Some of these measures require educators to seek permission from parents before they can teach students about topics like gender identity or sexuality. Others say that if a school employee is aware that a student identifies as trans, they can't withhold that information from the student's parents, nor can they encourage the student to withhold the information.
Other legislation, like Florida's so-called "Don't Say Gay" law, bans discussion of gender identity or sexual orientation in a manner that is not "age-appropriate" or "developmentally-appropriate." In the time since the bill was signed into law by the state's Republican governor, Ron DeSantis, similar measures have passed in Alabama and Arizona.
New laws go beyond restrictions on trans youth only
The anti-trans restrictions have been embraced almost exclusively by Republican lawmakers, a reflection of how the issue of trans rights has emerged as a galvanizing force for many within the base of the party.
Lawmakers who have sponsored these bills say they're needed to protect the rights of parents in raising their children, or to help uphold their religious beliefs.
"Parents need to know what's happening with their kids when they're at school," says Jay Richards, director of the DeVos Center for Life, Religion and Family at the Heritage Foundation, an influential conservative think tank. "Parents have the primary responsibility and prerogative to educate their children. They may delegate that to schools, but they don't give up their rights."
Richards also says he does not think "children can consent" to such consequential medical decisions as gender-affirming care.
Defenders also point to a handful of nations in Europe — including England, Finland and Sweden — that have moved in recent months to limit gender-affirming care for minors. Those restrictions – though generally more permissive than those in some U.S. states – have been driven by questions about the levels of screening and support for a large wave of new patients, as well as questions about the potential long-term health effects of puberty blockers, even though they've long been used to treat children with the medical condition known as "precocious puberty."
Many medical organizations, including the American Academy of Pediatrics, the Endocrine Society, the American Medical Association and the American Psychiatric Association, have publicly stated support for age-appropriate gender-affirming care and publish their own guidelines for care. Several have acknowledged the limited research into the potential long-term effects of puberty blockers, but still recommend it based on other research, especially studies that show positive improvements in mental health for patients.
In some cases, bills have been given a boost by conservative advocacy groups like the Heritage Foundation and Alliance Defending Freedom (ADF), according to lawmakers and advocates. The Southern Poverty Law Center has classified ADF as an anti-LGBTQ hate group. The group, which was involved in the Idaho ban on trans women and girls in sports, disputes the designation, writing in a statement that its legal cases in support of conservative causes "frequently draw broad support across ideological lines.
Many of the legislative proposals have gone beyond trans youth to target the trans community more broadly. Several states have moved — with mixed success — to limit access to public restrooms over the past two years, including Arkansas, Indiana, Iowa, Minnesota, Missouri, Oklahoma and Tennessee.
Idaho and Montana have tried to restrict residents from changing the sex that appears on their birth certificates. More recently, Oklahoma enacted a law that prevents gender markers other than male or female on birth certificates.
Other states, including Mississippi and Montana, have adopted laws that, according to critics, make it easier to discriminate against someone on the basis of their gender identity or sexual orientation. Supporters say the laws are needed to safeguard religious freedom.
Efforts to restrict trans rights haven't been limited to state capitols. In recent months, some Republican lawmakers in Congress have unsuccessfully sought to pass legislation restricting access to gender-affirming care for children, as well as discussion of gender identity in school curriculum and access to school sports for trans youth.
Advocates for trans rights have struggled to keep pace
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Advocates for LGBTQ rights have struggled to keep pace with the crush of new restrictions.
In June, President Biden signed an executive order aimed at increasing access to gender-affirming care and developing ways to combat state efforts to restrict such treatments for youth. And while states like California and Connecticut have moved to become safe havens for youth seeking gender-affirming care, the broader push to pass nondiscrimination protections on the basis of gender identity has had mixed success.
"It's a difficult moment to be passing proactive legislation because this is such a hot button issue all of a sudden," says Ames from the Trevor Project.
In all, less than half of all states explicitly ban discrimination in housing, jobs and public spaces on the basis of gender identity and sexual orientation, according to the Pew Research Center. These are protections that enjoy the support of 64% of Americans, according to Pew.
In many cases, the fight for new protections is being waged on the local level, according to Logan Casey, a senior policy researcher and adviser at Movement Advancement Project, a nonprofit think tank based in Colorado. But with all the changes happening on the state level, Casey says, the need for stronger federal protections is all the more vital.
"Your ability to be economically secure or to be safe in your community, to access best practice medical care should not depend on where you live," says Casey. "But unfortunately, it does."
The landscape has left Brandt, the Arkansas teen, fearful for his future. He knows he can always leave Arkansas if the state's ban on transgender care survives court challenges. But there's no guarantee he'll always be safe in a different state.
"It makes me worry that if I were to go somewhere else, if this happened here, why couldn't it happen somewhere else?" he says. "It's sad."
Methodology
NPR used data from several organizations that track anti-trans legislation, including ACLU, Freedom for All Americans, Movement Advancement Project, Trans Formations Project and the Trevor Project. Data on state level nondiscrimination protections was sourced from Pew Research Center.
NPR verified each piece of legislation by checking it against bill tracking or state legislature databases. NPR's analysis includes all states that have enacted anti-trans laws since 2021.
Laws in some states may be currently blocked due to court challenges. Some states may have other anti-trans policies beyond laws, such as executive orders. Other governing bodies or local entities within states, such as school boards or counties, may have their own restrictive policies.
Copyright 2023 NPR. To see more, visit https://www.npr.org.