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AAP continues to support care of transgender youths as more states push restrictions

January 6, 2022

As a record number of state bills targeting the rights of transgender youths were introduced in 2021, the AAP and other medical groups have stepped up efforts to protect them.

States introduced legislation to ban transgender youths from participating on athletic teams according to their gender identity, restrict access to school restrooms that align with students’ gender identity and prohibit health care professionals from providing or referring patients for gender-affirming care. Bills also seek to ban changes to birth certificates and uphold the right of religious refusal — allowing providers to refuse care based on claims of religious or moral beliefs.

The AAP has partnered with chapters and other entities to file amicus briefs in support of legal challenges brought by the American Civil Liberties Union (ACLU) in several states. AAP members and leaders also have been reaching out to state lawmakers to express concerns about harmful legislation.

“It is critically important for every child to have access to quality, comprehensive and evidence-based care — transgender and gender-diverse youth are no exception,” said AAP Immediate Past President Lee Savio Beers, M.D., FAAP. “As pediatricians, we will continue to speak up and advocate for our patients. We also want transgender and gender-diverse youth to know that not only do we care for them, we care about them, we value them and we will do all we can to ensure they have access to the care they need and deserve.”

Here is a look at state legislation on gender-affirming care bans and sports participation bans in 2021.

Gender-affirming care

Last April, Arkansas became the first state to pass a bill banning gender-affirming care for transgender youths and prohibiting health care providers from referring them for gender-affirming care. The law also prohibits public funding for such services and the state Medicaid program from covering it for those under age 18 years; private insurers could refuse to cover gender-affirming care for any youth.

The state legislature overrode the governor’s veto of this bill.

In May, the ACLU filed suit challenging the law, followed by a request for a preliminary injunction. The AAP’s amicus brief with 18 medical, mental health and educational organizations supported the injunction request. After a federal judge granted the injunction on July 21 halting implementation of the law, the state appealed.

The AAP and partners plan to submit a second amicus brief later this month.

Legislation in several states is being carried over to 2022 legislative sessions, and new bills have been filed in additional states.

In Texas, the governor requested and received a determination from the commissioner of its Department of Family and Protective Services that gender-affirming surgery for youth constitutes child abuse and neglect.

The AAP’s 2018 policy statement Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents defines gender affirmation as developmentally appropriate, nonjudgmental, supportive care provided in a safe clinical space.

The policy states that pediatric providers, often the first medical professionals to discover a child’s gender identity concerns, have a special role in caring for these patients who have a high risk of depression, anxiety and suicide.

The care model is not one-size-fits-all, said Brittany Allen, M.D., FAAP, a member of the AAP Section on LGBTQ Executive Committee. It recognizes the wide spectrum of normal, healthy gender identities.

“As I often tell families, gender-affirming care is creating space for children to be able to tell us their gender story, rather than filling in the end of the story for them. In that journey, gender-affirming care may draw on evidence-based medical tools — such as puberty blockers or hormone therapy — at developmentally appropriate ages. These tools have been shown to help reduce gender dysphoria and improve mental health for many transgender, nonbinary and gender-diverse youth.

“In my care of more than 200 transgender youth, I’ve seen the incredible relief and affirmation that these tools can provide,” said Dr. Allen, associate professor of pediatrics at University of Wisconsin School of Medicine and Public Health and co-director of a transgender clinic at American Family Children’s Hospital.

In 2021, a pediatrician submitted a resolution as part of the annual AAP Leadership Conference titled “Addressing Alternatives to the Use of Hormone Therapies for Gender Dysphoric Youth.”  It was not endorsed by any chapter, committee, council, section or district.

While any member can submit a resolution and any member can comment on submitted resolutions, only 57 out of the AAP's 67,000 members commented in support of the resolution. Ultimately, the resolution was soundly defeated by the voting members at the AAP Leadership Conference.

Unfortunately, some reports inaccurately reported this as reflecting “80% of the AAP membership,” and this figure is cited by proponents of the Arkansas law and similar efforts to ban gender-affirming care.

Debbie Greenhouse, M.D., FAAP, oversaw the resolution process as chair of the Chapter Forum Management Committee. She said that after discussion, the resolution “was overwhelmingly voted down in a clear statement that the majority of AAP leaders and experts believe that gender-affirming care is evidence-based, medically necessary care.”

Sports participation bans

Eight states enacted legislation to prohibit transgender youths from participating on athletic teams according to their gender identity in 2021. Laws in Alabama, Tennessee and Texas apply only to interscholastic athletics, while those in Arkansas, Florida, Mississippi, Montana and West Virginia apply to both interscholastic and collegiate athletics.

In South Dakota, the governor issued executive orders prohibiting transgender youths from participating on athletic teams according to their gender identity at the interscholastic level and recommending that only cisgender females play on female athletic teams at the collegiate level.

Idaho enacted a law in 2020 that banned transgender girls from playing on girls’ and women’s sports teams. The law has been on hold since the ACLU filed a legal challenge, which the AAP and other groups supported in an amicus brief.

The ACLU challenged a sports participation restriction law in West Virginia and a preliminary injunction was granted.

Laws also are being challenged in Florida, Montana and Tennessee.

In addition, pending legislation is being carried over in several states while new legislation has been introduced in other states.

Medical groups collaborate

In a March 2021 news release, Dr. Beers spoke out about how these bills threaten the health and well-being of transgender patients and interfere in the physician-patient-family relationship. She said the bills are dangerous, could leave transgender teens in certain areas without health care and criminalize pediatricians who try to care for them.

A joint statement in April 2021 from six major medical associations including the AAP noted the following: “Our organizations are strongly opposed to any legislation or regulation that would interfere with the provision of evidence-based patient care for any patient, affirming our commitment to patient safety.”

The patchwork nature of current laws protecting LGBTQ people leaves many youths subject to uncertainty and potential discrimination that impacts their safety, their families and their day-to-day lives, according to experts.

To address this, the Equality Act would provide explicit, permanent protections for LGBTQ people under the nation’s existing civil rights laws with regard to housing, education, federally funded programs and more. Such protections will help to protect LGBTQ youth from discrimination that threatens their health and well-being. The legislation passed the House of Representatives in spring 2021 and is currently awaiting a vote in the U.S. Senate.

The AAP led a sign-on letter of 140 organizations in support of the Equality Act and submitted testimony for the record supporting the legislation.

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