In 2023, as Missouri legislators inched closer to passing a ban on gender-affirming care for minors, Michael Walk, whose daughter is transgender, began making plans.
Alongside his family, the St. Louis TransParent chapter co-leader came up with four different scenarios for how his daughter, who was seventeen at the time, could continue to receive gender-affirming care. The ban in Missouri included an exception that would allow patients who started hormones and puberty blockers prior to August 2023 to continue that care. While Walk’s daughter qualified, they struggled to find willing local providers.
Plan A was simple—hope the law failed to pass, and that the Walks could continue accessing gender-affirming care in Missouri and living in the state. Plans B and C included staying in Missouri and making regular drives to the nearest clinic that offered gender-affirming care in Fairview Heights, Illinois, or, if that clinic wasn’t accepting new patients, a hospital farther away in Chicago. Plan D, the most costly, was to relocate to San Diego, California, where Walk’s daughter could continue receiving care and finish high school.
Stopping gender-affirming care wasn’t an option for Walk’s daughter, who struggled with prolonged bouts of depression prior to starting testosterone blockers in 2021, followed by estrogen treatments in 2022. Walk’s family was ultimately able to go with Plan B; the Missouri ban passed and was signed into law in June 2023, but the clinic in Fairview Heights took Walk’s daughter as a patient.
Since then, a slew of new state and federal legislation targeting gender-affirming care and transgender individuals have left Walk and his family continuing to plan contingencies for an uncertain future. While his daughter was in the process of choosing a college, she had to make sure the school was in a state where she would feel comfortable and safe in her identity, and where protections for transgender people were in place. She ruled out Missouri early on, and landed at a school in New York.
Since President Donald Trump resumed office in 2025, his administration has prioritized banning access to gender-affirming care. In Missouri, Kansas, and Colorado, three different paths are playing out that demonstrate how states and health care providers are responding—including implementing new bans, complying with federal directives despite state laws that say otherwise, and placing further restrictions on bans. In some places around the country, accessing gender-affirming care for transgender adults has also become more difficult.
Across the United States, twenty-seven states have implemented laws or policies limiting access to gender-affirming health care for minors, according to data from KFF. Of those states, twenty-four have also imposed professional or legal penalties on health care practitioners who provide minors with this care.
States largely took the lead on banning gender-affirming care for minors prior to it becoming a bigger focus of Trump’s second-term agenda. By 2023, nineteen states passed bans on gender-affirming care, the majority of which went into effect that same year. At the same time, at least ten states and Washington, D.C., passed “shield” laws to preserve access to this care. That included Colorado, which passed a law designating the state a safe haven for people undergoing gender-affirming care.
Though these current bans vary in structure, most of them apply to prescribing medication, like hormones, and providing surgical care, which is rare for minors. Many include penalties for health care providers, who could risk losing their medical licenses if they provide gender-affirming care. In eleven states, including Missouri, laws also explicitly prohibit Medicaid coverage from being used to cover gender-affirming care for minors and adults, according to data from the Movement Advancement Project, a nonprofit that tracks policies affecting LGBTQ+ people.
These laws cannot be viewed in isolation from other legislation targeting the transgender community, says Scott Skinner-Thompson, a professor at the University of Colorado Law School who specializes in Constitutional law and civil rights in relation to LGBTQ+ issues. While bans on gender-affirming care have largely targeted children, an increasing number of states are passing laws that target trans adults, including legislation invalidating driver’s licenses for transgender individuals in Kansas, and prohibiting transgender people from going into bathrooms that align with their gender identity in government buildings.
“If you can’t go to the state capital to advocate for your rights because you can’t use the bathroom in there, how are you going to advocate for your rights? If you can’t get an accurate identification document, how are you going to vote?” Skinner-Thompson says. “These barriers are pushing trans people from the public square. We need to stop thinking about these laws individually. They are part of a system that treats trans people as second-class citizens and segregates them from public life.”
In February 2025, after Kansas lawmakers passed a ban on gender-affirming care for minors, Amanda Mogoi held on to hope that some intervention might still stop it.
After all, previous attempts at a ban had fallen short—literally by one vote needed to override a veto by the state’s Democratic governor in 2023. Mogoi, owner and head clinician at M-Care Healthcare, a clinic in Wichita, Kansas, that provides services to the LGBTQ+ community, had spoken before the Kansas legislature advocating to preserve access to gender-affirming care for minors.
For the next ten months of 2025, M-Care kept appointments with minors until the end of December, just before the ban went into effect prohibiting providers from offering puberty blockers, hormone therapies, and surgeries for anyone under eighteen years old.
“I felt like, ‘We are not going to stop preemptively because maybe we can get an injunction in place or something that can block this,’ ” Mogoi says. “I’m not going to be the one who looks in [a] family’s eyes and tells them, ‘I’m sorry, I have to make it even harder for you to access care.’ ”
Mogoi’s experience used to be the opposite: As bans went into effect around the country, M-Care welcomed more patients from other states, including Nebraska and Oklahoma. That often meant patients and their parents were traveling to the clinic—some driving eight hours from Texas—for routine appointments multiple times a year, Mogoi says.
Mogoi opened M-Care in 2018 to provide health care to the transgender community, though she didn’t initially plan to treat minors. After fielding many requests to provide this care, it was clear to her there was significant need in the state; one of the only other nearby providers was about three hours away at the University of Kansas Health System. As neighboring states like Missouri passed bans on gender-affirming care, that need grew.
Now, with the Kansas ban in place, M-Care is redirecting patients to places where care is still accessible for minors, including New Mexico, Illinois, and Minnesota. Mogoi says some patients and their families have even left the country.
Patients may have to put off receiving care until they turn eighteen, a decision that can come with mental health risks for individuals. Mogoi worries others will take measures she would not advise as a clinician, such as “DIYing” their care by ordering medicine online or stockpiling medication.
“People are doing whatever they have to do to make it through the next two months until they turn eighteen, or the next year, or whatever that looks like,” Mogoi says. “They just made it harder for people to access care, but they didn’t make people stop accessing care. That is the point that these governments are missing: When we take away access to care, we make care less safe.”
Concerned over federal directives, some health care providers and hospitals residing in states without bans have preemptively paused or limited gender-affirming care.
“With health care providers under federal pressure, we’ve seen a lot of overcompliance from hospitals, even in states where it’s legal, complying with the Trump Administration’s illegal threats,” says Skinner-Thompson.
In January 2025, within days of resuming office, Trump issued several Executive Orders aimed at the LGBTQ+ community. One of those orders, titled “Protecting Children From Chemical and Surgical Mutilation,” directed organizations to limit the access of gender-affirming care—including puberty blockers, hormone therapies, and surgeries—for people under nineteen years of age. It was accompanied by threats to rescind federal funding for institutions that violated the order.
Legal pushback and lawsuits swiftly followed—actions that consistently halted the Executive Order in its tracks. That March, the district court in Maryland issued a preliminary injunction, effectively implementing a nationwide block on the Executive Order. But by July, one of the largest and oldest clinics in the country for transgender youth closed its doors at Children’s Hospital Los Angeles, citing federal pressures. In October, a clinic in Boston, Massachusetts, also announced a pause to its gender-affirming care, again citing pressures from the Trump Administration.
In December, Robert F. Kennedy Jr., Secretary of the Department of Health and Human Services (HHS), announced regulations to restrict puberty blockers, hormone therapy, and surgical interventions for transgender children. Hospitals that provided gender-affirming care would also be cut off from Medicare and Medicaid funding. That month, twenty-one states and Washington, D.C., sued to block the proposal; in April, a federal judge in Oregon put a stop to the directive, ruling it unlawful and an overreach of the health secretary’s authority.
After the directive from HHS, University of Wisconsin Health, Children’s Wisconsin, Children’s Minnesota, Children’s Hospital Colorado, and Denver Health—some of the largest hospitals in these states—all stopped care. Children’s Hospital Colorado, which suspended the care after the HHS Office of Inspector General opened an investigation into the hospital for providing gender-affirming care to minors, currently faces a lawsuit filed by some trans children and their families that would require the hospital to resume providing gender-affirming care.
Saint Louis University School of Law professor Heather McCabe says it’s concerning that providers in these states, long viewed as safe havens for the LGBTQ+ community, have “preemptively complied” with directives from the Trump Administration, despite there being no legal enforcement on the state or federal level. McCabe’s research focuses on how state policies affect health outcomes for the LGBTQ+ community.
She worries hospitals making these decisions could create a broader “chilling effect” that prompts other health care providers to pause care in states where it is affirmatively supported.
The disappearance of care in states without bans creates added confusion for providers, families, and patients who are already navigating an ever-changing legal landscape and a dwindling supply of states offering care. The changes in Colorado have prompted Mogoi and M-Care to stop directing patients to providers in the state, despite being a nearby option for Kansas patients.
“When we see health care taken away through unenforceable mechanisms, it’s really concerning because what it suggests is we don’t have to have a real, enforceable law to change access to care that we know is life-saving,” McCabe says. “I have real concerns for what that’s going to mean long-term for health care for folks who are trans in this country.”
Since opening her private practice in 2018, clinical psychologist Lori Becker became a go-to referral for patients seeking letters that assessed their readiness for gender-affirming care by endocrinologists at the Washington University Transgender Center in St. Louis, a clinic well-regarded for its gender treatments for adults and adolescents.
All that changed in August 2023, when Missouri’s ban on gender-affirming care for minors went into effect. Earlier that year, the clinic at Washington University became the subject of national political controversy and a Missouri attorney general investigation, after whistleblower complaints claimed the clinic had rushed prescribing hormones to minors. Those complaints also became fodder for lawmakers in Missouri and other states focused on passing bans on gender care for minors.
That year, Becker was named in a complaint filed by the Missouri attorney general’s office against the Washington University Transgender Center. The complaint mentioned that Becker wrote some letters of support for patients seeking gender-affirming care, and she had to turn over two patient files to the state licensing board for psychologists. In summer 2024, she had to hire an attorney, miss multiple days of work, and face questions about her practice from the licensing board, which is obligated to investigate any complaints made against licensed psychologists. Following Becker’s hearing and a review of the information she provided, the committee decided not to pursue the matter any further and closed the case.
“That’s scary for a provider,” Becker says. “That’s my license. This is my career. This is my livelihood.”
While there is no current legislation barring psychologists from seeing minors for evaluations, including for those who reside out of state, Becker says she stopped offering those services after going through her ordeal with the attorney general. Previously, she would see about six to eight minors per year, mostly ages fifteen or older, for evaluations.
“I am way too scared to see minors after what happened,” Becker says. “What’s happening a lot in the transgender health care provider community is people are just very scared about liability and the risk of losing their license.”
Those evaluations came with several protocols for minors seeking gender-affirming care, including for hormones or surgery, as directed by guidelines from WPATH, the World Professional Association for Transgender Health. A patient had to meet certain criteria to receive a gender dysphoria diagnosis and to find a medical provider. The patient and their parents or legal guardians would also need to be interviewed separately. At the end of those sessions, Becker would decide whether or not to write a referral letter, which attested to the patient’s and the parents’ understanding and ability to consent to gender-affirming care as well as the patient’s readiness to undergo changes that can be permanent. If a minor wanted surgery, that patient would usually need to undergo months of hormone therapy prior. A minor would then have to go through the entire evaluation process a second time, with a different licensed mental health care provider, to ensure consensus between the two providers about the patient’s readiness for care.
Before Missouri’s ban, minors seeking gender-affirming care had to obtain parental permission, in addition to two referral letters: one from at least a master’s level clinician, and another from a psychiatrist or psychologist with an M.D., Psy.D., or Ph.D., like Becker.
“People in the public don’t have enough of an understanding of the level of evaluation that actually is part of that,” Becker explains. “That is done in the exact same way we do psychological evaluations before bariatric surgery or an organ transplant,” two other forms of permanent medical procedures.
Missouri’s current ban includes a sunset provision that places a moratorium on hormone therapy and puberty blockers for minors under eighteen, which is set to expire in 2027. (Surgery for minors, which is not included with the sunset provision, was already permanently banned in the state.) Lawmakers now are seeking to remove this sunset provision and considering a permanent ban on this care. The Missouri House passed the legislation in February, which now awaits approval from the state Senate.
As gender-affirming care disappears for minors, some lawmakers have also attempted to extend these bans to adults. Lawmakers in Oklahoma previously introduced a bill that would prohibit gender-affirming care for people up to the age of twenty-six, though it failed to pass into law. Last year, a Texas lawmaker proposed a bill that would make gender-affirming care illegal for people of all ages. Missouri’s ban on gender-affirming care also applies to incarcerated adults.
Hazel Krebs, a forty-four-year-old transgender woman in Kansas, is concerned about what access to gender-affirming care will look like in the future.
“I’ll be on estrogen for the rest of my life, but it’s the same estrogen that postmenopausal women are on,” Krebs says. “I’m worried about it, but also, how do you legislate that?”
She’s more concerned about health care providers, including mental health care providers who specialize in serving the LGBTQ+ community, leaving the state.
“When you start seeing therapists leave, that affects everybody,” Krebs says. “That’s where the concern is, that individual health care providers or mental health providers will start leaving. Why would they stay?”