What is gender-affirming care?
Gender-affirming care is medical treatment that helps transgender and gender-diverse people live in ways consistent with their gender identity. It includes mental health support, puberty blockers, hormone therapy, and surgical procedures for adults.
Gender-affirming care is an umbrella term for treatments that the American Academy of Pediatrics, American Medical Association, and World Professional Association for Transgender Health all endorse as evidence-based. The care is not new. Endocrine treatments for gender dysphoria have been used for decades.
Key facts
- 55+ medical organizations representing 600,000+ physicians support gender-affirming care (Brandt et al., Transgender Health 2024)
- 26 states passed bans on gender-affirming care for minors. 22 full bans are enforced. Courts blocked three. Arizona bans surgery only. (KFF Policy Tracker, MAP)
- 60% lower odds of moderate-to-severe depression within the first year of care (Tordoff et al., JAMA Network Open 2022)
- 1.94% pooled surgical regret rate, lower than knee replacement (6-30%) or hip replacement (7-10%) (Bustos et al., 2024)
- No center in the United States performs genital surgery on minors (WPATH SOC8)
This page is not medical advice. It summarizes current clinical standards, published research, state policy, and federal actions. Medical decisions belong with patients, families, and qualified clinicians.
The care is not a single treatment. It is a spectrum that starts with social support and counseling, may include reversible puberty blockers, and progresses to hormones or surgery only after months or years of clinical evaluation. Most people who receive care are adults.
- 55+
- medical orgs support this care
- 60%
- lower depression with treatment
- 1.94%
- surgical regret rate
If you’re trans or nonbinary, none of this politics changes who you are. Trevor Project: 1-866-488-7386 or text START to 678-678, 24/7. Trans Lifeline: 877-565-8860, staffed by trans people.
How Doctors Decide Who Gets Care
The process involves multiple providers, months of evaluation, and formal criteria at every stage. Accredited programs do not hand out hormones after one visit. The typical pathway moves through distinct steps: counseling and social support first, then assessment by trained providers, then puberty-stage evaluation if relevant, then parent permission and youth assent for minors, then reversible blockers when clinically appropriate, then hormones only after further evaluation, and surgery mostly limited to adults.
The WPATH Standards of Care, 8th Edition (2022) and the Endocrine Society Clinical Practice Guidelines (2017) set the clinical framework. Both require a comprehensive biopsychosocial assessment before any medical intervention.
WPATH SOC8 and Endocrine Society criteria by treatment type
| Treatment | Who qualifies | Requirements | Reversibility |
|---|---|---|---|
| Puberty blockers | Adolescents at Tanner Stage 2 (puberty onset, typically ages 9-14) | Documented gender dysphoria that worsened with puberty. Mental health provider confirmation. Parental permission + adolescent assent. | Fully reversible. Puberty resumes if stopped. |
| Hormone therapy | Adolescents (capacity-based, typically 12-16+) and adults | Multidisciplinary team confirms persistent dysphoria. Mental health provider required for adolescents. Gradual dose schedule. | Partially irreversible. Informed consent required. |
| Top surgery | Some centers allow for teens 16+ with parent and provider agreement | Persistent dysphoria. Mental health evaluation. Parental consent for minors. | Irreversible. |
| Genital surgery | Adults 18+ only. No center performs on minors. | 12 months of hormone therapy. 12 months in desired gender role. Two mental health referral letters from different providers. | Irreversible. |
The assessment period alone takes months to years depending on the complexity of the case. The Endocrine Society Transition Readiness Assessment asks whether the patient can explain their diagnoses, advocate for their own care, and manage appointments independently. Providers evaluate family support, mental health stability, and informed consent capacity.
For minors, the process is family-centered. Parents provide permission. Adolescents provide assent. A mental health professional must confirm that dysphoria is long-lasting, intensified with puberty, and not better explained by another condition. Adults provide their own consent and need fewer gatekeeping steps, but the assessment is still required before hormones and mandatory before surgery.
Mental Health Outcomes and Regret Rates
The medical evidence compares outcomes for people who received gender-affirming care against those who did not. The direction is consistent across studies. People who receive care do better on every mental health measure.
Youth who received care within the first year had 60% lower odds of moderate-to-severe depression and 73% lower odds of self-harm or suicidal thoughts (Tordoff et al., JAMA Network Open 2022).
When care was delayed 3-6 months, patients were 2-3x more likely to experience depression or suicidality.
Documented outcomes: with care vs. without care
| Measure | With care | Without care |
|---|---|---|
| Suicide risk | 73% lower (Tordoff et al., JAMA 2022) | 73% higher. 9 in 10 who wanted blockers but didn't get them contemplated suicide (AAMC/Turban). |
| Depression | 60% lower moderate-to-severe (Tordoff 2022) | Worsening over 12 months without treatment |
| Mental health overall | Comparable to cisgender peers (Toomey et al., 2022) | Worse than cisgender peers on every measure |
| Regret rate | 1.94% (Bustos et al., 2024) | N/A (no treatment to regret) |
| Continuation | 98% of youth who start as adolescents continue as adults | N/A |
| Long-term benefit | 40% lower suicidal ideation for adults who accessed hormones during adolescence (Turban, PLOS ONE 2022) | Worse outcomes if care delayed to adulthood |
The surgical regret rate for gender-affirming procedures deserves its own context. A 2024 meta-analysis pooling data across studies found a 1.94% surgical regret rate with a 95% confidence interval under 2%. Regret after knee replacement surgery runs 6-30%. Hip replacement: 7-10%. Of the small number of people who detransitioned, 11% cited external factors like parental pressure or financial barriers, and only 2% cited internal uncertainty about their identity (AAMC).
Common Claims vs the Evidence
Each of these claims about gender-affirming care circulates in political debate. Each is contradicted by published evidence.
Claims about gender-affirming care vs. documented evidence
| The claim | The evidence |
|---|---|
| "Children are getting surgery" | No center in the U.S. performs genital surgery on minors. Top surgery is rare and available only for teens 16+ with parent and provider agreement. (WPATH SOC8) |
| "It's experimental" | 55+ medical organizations support it. WPATH SOC8 draws on decades of evidence. Puberty blockers have been FDA-approved for precocious puberty since the 1990s. |
| "Social contagion is causing more kids to identify as trans" | "Rapid-onset gender dysphoria" is not a medical diagnosis. Increased visibility correlates with people feeling safer to come out. 98% of youth who start care continue. (Multiple studies) |
| "The regret rate is high" | 1.94% pooled surgical regret rate. Lower than knee replacement (6-30%) or hip replacement (7-10%). (Bustos et al., 2024) |
| "Puberty blockers are dangerous" | FDA-approved for decades for precocious puberty. Fully reversible when stopped. (Endocrine Society Guidelines, 2017) |
| "Kids are too young to know" | Average coming-out age for Gen Z is 14. Clinical assessment takes months to years. No treatment is immediate. (WPATH SOC8) |
| "It's care on demand" | Multiple gatekeeping steps: biopsychosocial assessment, mental health evaluation, parental consent, multidisciplinary team review. See How Doctors Decide section above. |
| "European countries banned it" | They restricted one pathway (puberty blockers as first-line). They still provide hormones, surgery, and comprehensive adult care. U.S. bans prohibit all medical interventions. |
| "The Cass Review proves it doesn't work" | Cass found weak evidence for some interventions and recommended a research model, not bans or criminal penalties. WPATH formally objected that the review applied pharmaceutical trial standards to a field where RCTs are ethically impossible. |
| "Parents are pushing kids into it" | 11% of detransitioners cited parental pressure to STOP transitioning, not to start. 2% cited internal uncertainty. (AAMC) |
26 States Banned Care for Minors
Whether a transgender teenager can access care depends on where they live. Twenty-six states passed bans on gender-affirming care for minors. Twenty-two full bans are currently enforced. Courts blocked three. Arizona bans surgery only while protecting other care by executive order. Fourteen states and D.C. passed shield laws protecting families who travel for care. Two more states issued executive orders with similar protections.
Sources: Movement Advancement Project, KFF Policy Tracker, UCLA Williams Institute. June 2026.
| State | Status | Detail |
|---|---|---|
| Alabama | Care ban in effect | Felony to provide care. Up to 10 years. |
| Arizona | Surgical ban only | Surgical care banned. Medication and other care protected by governor's executive order. |
| Florida | Care ban in effect | Full ban. Trans youth drive 8.5 hours further for care. |
| Georgia | Care ban in effect | Surgery and hormone therapy banned. |
| Iowa | Care ban in effect | Full ban on hormones, blockers, surgery. |
| Idaho | Care ban in effect | Felony to provide care. |
| Indiana | Care ban in effect | Full ban on medical interventions for minors. |
| Kentucky | Care ban in effect | Hormones and surgery banned for minors. |
| Louisiana | Care ban in effect | Full ban on hormones, blockers, surgery. |
| Missouri | Care ban in effect | Full ban on gender-affirming care for minors. |
| Mississippi | Care ban in effect | Full ban on medical interventions for minors. |
| Montana | Ban blocked by court | Ruled unconstitutional May 2025 on state constitutional grounds. Survives Skrmetti. |
| North Carolina | Care ban in effect | Hormones and surgery banned for minors. |
| North Dakota | Care ban in effect | Full ban on medical interventions for minors. |
| Nebraska | Care ban in effect | Full ban on hormones and surgery for minors. |
| Ohio | Care ban in effect | Full ban enacted. |
| Oklahoma | Care ban in effect | Full ban on gender-affirming care for minors. |
| South Carolina | Care ban in effect | Full ban on medical interventions for minors. |
| South Dakota | Care ban in effect | Full ban enacted. |
| Tennessee | Care ban in effect | Full ban. Upheld by SCOTUS in Skrmetti (6-3). |
| Texas | Care ban in effect | Full ban. 500+ families organized through TKFTX. |
| Utah | Care ban in effect | Full ban on hormones and surgery for minors. |
| West Virginia | Care ban in effect | Full ban on medical interventions for minors. |
| Wyoming | Care ban in effect | Full ban enacted. |
| Arkansas | Ban blocked by court | First state to pass a ban (2021). Currently enjoined. |
| Kansas | Ban blocked by court | Judge halted ban May 2026, questioned credibility of state witnesses. |
| California | Shield law protects access | Statutory protections for providers and families. |
| Colorado | Shield law protects access | Statutory protections for providers and families. |
| Connecticut | Shield law protects access | Statutory protections for providers and families. |
| District of Columbia | Shield law protects access | Statutory protections for providers and families. |
| Illinois | Shield law protects access | Statutory protections for providers and families. |
| Maine | Shield law protects access | Statutory protections for providers and families. |
| Maryland | Shield law protects access | Statutory protections for providers and families. |
| Michigan | Shield law protects access | Statutory protections for providers and families. |
| Minnesota | Shield law protects access | Statutory protections for providers and families. |
| New Jersey | Shield law protects access | Statutory protections for providers and families. |
| New Mexico | Shield law protects access | Statutory protections for providers and families. |
| New York | Shield law protects access | Statutory protections for providers and families. |
| Oregon | Shield law protects access | Statutory protections for providers and families. |
| Vermont | Shield law protects access | Statutory protections for providers and families. |
| Washington | Shield law protects access | Statutory protections for providers and families. |
| Massachusetts | Executive order protection | Governor issued executive protection order. |
| Rhode Island | Executive order protection | Governor issued executive protection order. |
| Alaska | No ban, no shield law | No legislation on gender-affirming care for minors. |
| Delaware | No ban, no shield law | No legislation on gender-affirming care for minors. |
| Hawaii | No ban, no shield law | No legislation on gender-affirming care for minors. |
| New Hampshire | No ban, no shield law | No legislation on gender-affirming care for minors. |
| Nevada | No ban, no shield law | No legislation on gender-affirming care for minors. |
| Pennsylvania | No ban, no shield law | No legislation on gender-affirming care for minors. |
| Virginia | No ban, no shield law | No legislation on gender-affirming care for minors. |
| Wisconsin | No ban, no shield law | No legislation on gender-affirming care for minors. |
48% of trans youth ages 13-17 live in states with bans or restrictions (Williams Institute). In the South, 95% of trans youth live in states with restrictive laws. Six states classify providing care as a felony.
- 22
- full state bans currently enforced
- 48%
- of trans youth in ban states
- 6
- states make care a felony
Who Is Behind the Bans
The gender-affirming care bans did not emerge independently. The same organizations that fund the broader anti-LGBTQ movement and Christian nationalism campaign coordinate the legal strategy against gender-affirming care.
- Wrote the legal framework Alliance Defending Freedom $119.8M/year. SPLC-designated hate group. ↓ ADF drafted model care ban legislation
- Distributed model bills to 26 states Heritage Foundation $133.8M revenue. Published Project 2025. ↓ State legislators introduced near-identical bills
- Passed bans with minimal changes to the template 26 state legislatures 22 full bans enforced. 3 blocked by courts. 6 classify care as a felony. ↓ Tennessee's ban challenged up to SCOTUS
- Skrmetti (2025): upheld Tennessee ban 6-3 U.S. Supreme Court Every other state with a ban now has legal cover to enforce it.
Sources: IRS 990 filings, SPLC, SCOTUSblog
From model bill to Supreme Court precedent: Alliance Defending Freedom ($119.8M/year. SPLC-designated hate group.) — ADF drafted model care ban legislation — Heritage Foundation ($133.8M revenue. Published Project 2025.) — State legislators introduced near-identical bills — 26 state legislatures (22 full bans enforced. 3 blocked by courts. 6 classify care as a felony.) — Tennessee's ban challenged up to SCOTUS — U.S. Supreme Court (Every other state with a ban now has legal cover to enforce it.)
The care ban language is nearly identical across 26 states because it comes from the same sources. ADF wrote the legal framework. Heritage distributed model bills. State legislators introduced them with minimal changes. The Supreme Court, in United States v. Skrmetti (2025), upheld Tennessee’s ban in a 6-3 ruling, giving every other state legal cover to enforce its law.
After the Obergefell marriage decision made same-sex marriage bans unenforceable, the anti-LGBTQ legal infrastructure pivoted. Within five years, the same organizations shifted from fighting marriage to criminalizing healthcare.
- WPATH founded Originally HBIGDA. First clinical standards for transgender care.
- Dutch Protocol developed Puberty blockers introduced for adolescents with gender dysphoria.
- Obergefell decided Marriage equality settled. Anti-trans pivot begins within months.
- Arkansas passes first care ban HB 1570. Courts block enforcement. Template for 25 more states.
- WPATH SOC8 published 100+ international experts update clinical standards.
- Alabama makes care a felony Up to 10 years in prison for providing care to minors.
- 509 anti-trans bills filed First year to cross 500. Bans spread to 20+ states.
- Cass Review published (UK) Found weak evidence for some youth interventions. Recommended research model, not bans.
- SCOTUS upholds Tennessee ban Skrmetti: 6-3. States have authority to regulate minors' care.
- Federal funding threats 12+ hospitals stop care even in states without bans.
From clinical standards to state bans, 1979-2026: 1979 — WPATH founded (Originally HBIGDA. First clinical standards for transgender care.). 1998 — Dutch Protocol developed (Puberty blockers introduced for adolescents with gender dysphoria.). 2015 — Obergefell decided (Marriage equality settled. Anti-trans pivot begins within months.). 2021 — Arkansas passes first care ban (HB 1570. Courts block enforcement. Template for 25 more states.). 2022 — WPATH SOC8 published (100+ international experts update clinical standards.). 2022 — Alabama makes care a felony (Up to 10 years in prison for providing care to minors.). 2023 — 509 anti-trans bills filed (First year to cross 500. Bans spread to 20+ states.). 2024 — Cass Review published (UK) (Found weak evidence for some youth interventions. Recommended research model, not bans.). 2025 — SCOTUS upholds Tennessee ban (Skrmetti: 6-3. States have authority to regulate minors' care.). 2026 — Federal funding threats (12+ hospitals stop care even in states without bans.).
1979: The World Professional Association for Transgender Health was founded as the Harry Benjamin International Gender Dysphoria Association. It published the first clinical standards of care for transgender patients.
1998: Researchers at the VU University Medical Center in Amsterdam developed the Dutch Protocol, introducing puberty blockers as a treatment for adolescents with gender dysphoria. The protocol became the clinical foundation used worldwide.
2015: The Supreme Court decided Obergefell v. Hodges, establishing marriage equality. The conservative legal infrastructure that had spent decades fighting same-sex marriage pivoted to trans healthcare. ADF and Heritage shifted their model legislation within months.
2021: Arkansas became the first state to pass a ban on gender-affirming care for minors. Courts blocked enforcement, but the bill became a template. Twenty-five more states followed.
2025: The Supreme Court ruled 6-3 in U.S. v. Skrmetti that Tennessee’s care ban did not require heightened constitutional scrutiny. The ruling gave every state with a pending ban legal cover to enforce it.
The Federal Threat, 2025-2026
Twenty-six states banned care through their own legislatures. The federal government is now using executive orders, funding rules, and agency pressure to extend the restrictions nationwide.
Executive Order 14187 (January 2025) directed federal agencies to rescind all policies relying on WPATH guidelines. The Senate HELP Committee called on WPATH to comply, describing evidence-based care as “chemical and surgical mutilation.”
CMS proposed rules in December 2025 that would prohibit Medicaid and CHIP from covering gender-affirming care for anyone under 18. A separate ACA Marketplace rule bans coverage starting plan year 2026.
The conflict between the medical system and the political system is direct.
How the medical process and the political response diverge
| What the medical system does | What the political system does |
|---|---|
| Evaluates whether a patient is eligible | Bans entire categories of care |
| Determines what treatment is appropriate | Threatens provider funding |
| Weighs risks and benefits with the patient | Adds criminal or professional penalties |
| Obtains informed consent from patient and family | Removes family and provider discretion |
The federal pressure reached hospitals in states without bans. 12+ hospitals stopped providing care after funding threats, including facilities in California, Illinois, and New York (NPR, April 2026). Vanderbilt University Medical Center in Tennessee stopped gender-affirming surgeries for adults (Southern Equality). Baystate Health in Massachusetts ceased youth gender medications in February 2026.
| Period | Value |
|---|---|
| 2020 | Growing network of specialized clinics across the U.S. |
| 2026 | Dozens of programs closed in ban states and blue states alike |
| Change | Providers closing even where care is legal |
In June 2026, the Texas Attorney General forced Texas Children’s Hospital to open a detransition clinic and pay $10 million as part of a settlement over care it had already provided legally. The same month, the administration’s Ryan White HIV/AIDS Program rules now bar providers from offering gender-affirming care as a condition of receiving federal HIV funding. Lambda Legal filed suit.
Federal courts issued temporary relief. A Maryland judge granted a 14-day nationwide restraining order blocking HHS funding conditions in February 2025. Washington state obtained a similar order covering Washington, Oregon, and Minnesota. Both measures are temporary and may expire without further intervention.
Did Europe Ban Gender-Affirming Care?
The claim that “European countries banned gender-affirming care” is used to justify U.S. state bans. The claim misrepresents what happened. European countries restricted one pathway. They did not ban care.
European approaches vs. U.S. state bans
| Country | What changed | What remains available | U.S. comparison |
|---|---|---|---|
| United Kingdom | Puberty blockers restricted to clinical trials only (2024, after Cass Review) | Hormones, surgery, and mental health support for adults. | U.S. bans prohibit ALL medical care for minors: blockers, hormones, and surgery. |
| Sweden | Hormones restricted to "exceptional cases" for under-18s (2022) | Comprehensive adult care. Psychotherapy prioritized for adolescents. | U.S. bans have no exception for severe cases. |
| Finland | Prioritizes psychotherapy first for adolescents | Hormones still available as second-line treatment. Adult care unchanged. | U.S. bans prohibit hormones entirely. |
| Netherlands | Where the Dutch Protocol (puberty blockers) originated | Still provides comprehensive care for adolescents and adults. | U.S. bans reject the science the Dutch Protocol created. |
| Denmark | Restricted hormone treatment to a single national center | Care still available through centralized program. | U.S. bans eliminate care entirely. |
The Cass Review (UK, 2024) found weak or low-certainty evidence for some youth interventions and recommended a more centralized, research-oriented model in England. It did not recommend criminal penalties or broad legislative bans. WPATH and USPATH formally objected to the review’s methodology, arguing it applied evidence standards designed for pharmaceutical trials to a field where randomized controlled trials are ethically impossible. You cannot give a control group of dysphoric teenagers a placebo and withhold treatment for years.
European countries restricted certain treatments for adolescents while keeping adult care intact and making adolescent care available through specialized pathways. U.S. state bans prohibit all medical interventions for minors and, in some cases, adults.
What Families and Providers Face in Ban States
In states where care was banned, families faced immediate consequences. Some relocated across state lines. Others drove hundreds of miles each way for appointments in neighboring states. 500+ families in Texas organized through Trans Kids and Families of Texas rather than uproot their lives (TKFTX).
Human Rights Watch documented families in ban states who watched their children’s mental health deteriorate after established treatment plans were interrupted. Providers who had managed a patient’s care for years were forced to stop overnight.
The mental health data tracks the impact of care bans on LGBTQ youth. 44% of LGBTQ youth who needed mental health care could not access it (Trevor Project 2025). The 988 Suicide and Crisis Lifeline’s LGBTQ+ youth subnetwork had its federal funding cut in July 2025. The CDC’s 2023 Youth Risk Behavior Survey found that 41% of LGBTQ+ high-school students seriously considered suicide, compared with 13% of their heterosexual peers.
- 44%
- of LGBTQ youth couldn't get mental health care (Trevor 2025)
- 41%
- of LGBTQ students considered suicide (CDC 2023)
- 12+
- hospitals stopped care after federal threats
The provider shortage extends beyond ban states. When hospitals in blue states close their youth programs preemptively, families who thought they were protected discover they are not. The waiting lists at remaining clinics grow. The distance to care increases. The families with money travel. The families without money wait.
If there is any talk of violence or self-harm, this is no longer a conversation problem. Call 911 if someone is in immediate danger. Call or text 988 (Suicide and Crisis Lifeline) if someone is in a mental health crisis. For LGBTQ youth, contact the Trevor Project: call 1-866-488-7386 or text START to 678-678.
Frequently asked questions
What does gender-affirming care include? It ranges from social support (chosen name, pronouns, clothing) through reversible puberty blockers, partially irreversible hormone therapy, and irreversible surgery. Each step requires its own clinical evaluation. Most people who receive care are adults.
Do children get surgery? No U.S. center performs genital surgery on minors. Top surgery (chest) is available at some centers for teens 16 and older with parental consent and provider agreement. The vast majority of surgical patients are adults over 18.
Are puberty blockers safe? Puberty blockers have been FDA-approved for decades for children with precocious (early) puberty. When used for gender dysphoria, they pause the onset of puberty. If stopped, puberty resumes. The Endocrine Society classifies them as fully reversible.
What is the Cass Review? An independent review of gender-affirming care in England published in 2024. It found weak or low-certainty evidence for some youth interventions and recommended a centralized, research-oriented model. It did not recommend criminal penalties or legislative bans. WPATH and USPATH formally objected to the review’s methodology, arguing it applied pharmaceutical trial standards to a population where randomized controlled trials are ethically impossible.
What are shield laws? Laws passed by 14 states and D.C. that protect providers and families from prosecution if they cross state lines to access legal care. Two additional states have executive orders with similar protections. Eight states protect both reproductive healthcare and gender-affirming care under the same statute.
What happened in the Skrmetti case? In June 2025, the Supreme Court ruled 6-3 in U.S. v. Skrmetti that Tennessee’s ban on gender-affirming care for minors did not require heightened constitutional scrutiny. The ruling gave legal cover to every other state with a ban.
What you can do
-
Tell your members of Congress to oppose the CMS rules banning Medicaid coverage for minors. Name the specific rule numbers: CMS-2025-1823 and CMS-2025-23464. These rules would bar any Medicaid-certified hospital from providing gender-affirming care for patients under 18, including in states where care is legal. Use the letter below.
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Support shield law legislation in your state. If your state has not passed a shield law, contact your state legislators and ask them to introduce one. Shield laws protect families from prosecution when they cross state lines for legal medical care. Movement Advancement Project tracks which states have protections and which do not.
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Know where to find care. Trans Lifeline (877-565-8860) provides crisis support and connects callers to resources. The Trevor Project (1-866-488-7386, text START to 678-678) serves LGBTQ youth under 25. FOLX Health and Plume provide telehealth gender-affirming care in states where it remains legal.
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Donate to organizations defending access. The ACLU is challenging bans in multiple states. Lambda Legal litigates on behalf of trans youth and families. Southern Equality tracks provider availability in the South and maintains a Trans Healthcare Fund for families who need help covering travel and care costs.
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Share accurate information. The “Common Claims vs the Evidence” table above is designed to be shared. When someone repeats a claim about care being experimental or children getting surgery, the sourced data is what changes the conversation.
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Write your representative about opposing federal restrictions on gender-affirming care. Use the letter below.