Representatives from Georgia, Tennessee, Arkansas, Arizona, and Nebraska express their concerns with the increase of and access to care for gender dysphoria.

_{"There has been a massive unexplained rise in diagnoses of gender dysphoria among children over the past ten years, with most of those experiencing this phenomenon being girls;" (G.A. Gen. Assemb, 2023).}

_{"The legislature finds that such medical procedures are being performed on and administered to minors in this state with rapidly increasing frequency and that supposed guidelines advocating such treatment have changed substantially in recent years" (T.N. Gen. Assemb, 2023).}

_{"Genital and nongenital gender altering surgeries are generally not recommended for children, although evidence indicates referral for children to have such surgeries are becoming more frequent;" (N.E. State Legislature, 2023).}

_{"Genital and nongenital gender reassignment surgeries are generally not recommended for children, although evidence indicates referrals for children to have such surgeries are becoming more frequent;" (A.R. Gen. Assemb, 2021).}

_{"Between 2015 and 2016, gender reassignment surgeries increased by nearly twenty percent (20%) in the United States;" (A.R. Gen. Assemb, 2021).}

_{"Genital and nongenital gender reassignment surgeries are generally not recommended for children, although evidence indicates referrals for children to have such surgeries are becoming more frequent" (A.Z. State Legislature, 2022).}

_{"It is an accepted principle of economics and public policy that when a service or product is subsidized or reimbursed, demand for that service or product is increased. Between 2015 and 2016, gender reassignment surgeries increased by nearly twenty percent in the United States" (A.Z. State Legislature, 2022).}

_{"Gender dysphoria is often comorbid with other mental health and developmental conditions, including autism spectrum disorder;" (G.A. Gen Assemb, 2023).}

_{"Even among people who have undergone inpatient gender reassignment procedures, suicide rates, psychiatric morbidities, and mortality rates remain markedly elevated above the background population;" (A.R. Gen. Assemb, 2021).}

_{"Furthermore, scientific studies show that individuals struggling with distress at identifying with their biological sex often have already experienced psychopathology, with indicates these individuals should be encouraged to seek mental health services to address comorbidities and underlying causes of their distress before undertaking any hormonal or surgical intervention;" (A.R. Gen. Assemb, 2021).}

_{"Several studies demonstrate that hormonal and surgical interventions often do not resolve the underlying psychological issues affecting the individual. For example, individuals who undergo cross-sex cosmetic surgical procedures have been found to suffer from elevated mortality rates higher than the general population. They experience significantly higher rates of substance abuse, depression, and psychiatric hospitalizations" (A.L. State Legislature, 2022).}

_{"Recent science suggests that medical interventions like surgeries can cross-sex hormones do not significantly improve long-term health outcomes for patients struggling with gender dysphoria and that suicide rates, psychiatric morbidities, and mortality rates remain markedly elevated above the background population after inpatient gender reassignment procedures have been performed" (I.D. State Legislature, 2023).}

_{"Furthermore, scientific studies show that individuals experiencing distress at identifying with their biological sex often experienced psychopathology preceding their gender dysphoria, which indicates these individuals should be encouraged to seek mental health services" (A.Z. State Legislature, 2022).}

_{"Even among people who have undergone inpatient gender reassignment procedures, suicide rates, psychiatric morbidities and mortality rates remain markedly elevated above the background population" (A.Z. State Legislation, 2022).}

Representatives from Georgia, Nebraska, Tennessee, Alabama, and Idaho share their concerns on the irreversibility of certain treatments for gender dysphoria.

_{"Certain medical treatments for gender dysphoria, including hormone replacement therapies and surgeries, have permanent and irreversible effects on children;" (G.A. Gen. Assemb, 2023).}

_{"Genital and nongential gender altering surgery includes several irreversible and invasive procedures for biological males and biological females and involves the alteration of biologically healthy and functional body parts" (N.E. State Legislature, 2023).}

_{"The legislature determines that medical procedures that alter a minor's hormonal balance, remove a minor's sex organs, or otherwise change a minor's physical appearance are harmful to a minor when these medical procedures are performed for the purpose of enabling a minor to identify with, or live as, a purported identity inconsistent with the minor's sex or treating purported discomfort or distress from a discordance between the minor's sex and asserted identity. These procedures can lead to the minor becoming irreversibly sterile, having increased risk of disease and illness, or suffering from adverse and sometimes fatal psychological consequences..." (T.N. Gen. Assemb, 2023).}

_{"Puberty blockers prevent gonadal maturation and thus render patients taking these drugs infertile. Introducing cross-sex hormones to children with immature gonads as a direct result of pubertal blockade is expected to cause irreversible sterility. Sterilization is also permanent for those who undergo surgery to remove reproductive organs, and such persons are likely to suffer through a lifetime of complications from the surgery, infections, and other difficulties requiring yet more medical intervention" (A.L. State Legislature, 2022).}

_{"Some healthcare providers now routinely administer cross-sex hormones to pubescent children notwithstanding scientific evidence that such therapies cause irreversible sterility and likely increase risks of other medical conditions, including cancer, cardiovascular disease, blood clots, osteoporosis, and obesity" (I.D. State Legislature, 2023).}

_{"Genital gender reassignment surgery includes several irreversible invasive procedures for males and females and involves the alternation of biologically healthy and functional body parts..." (A.Z. State Legislature, 2022).}

Representatives from Tennessee share their concern about the true motives behind treatment for gender dysphoria, such as gender reassignment surgery.

_{"The legislature finds that many of the same pharmaceutical companies that contributed to the opioid epidemic have sought to profit from the administration of drugs to or use of devices on minors for such purposes and have paid consulting fees to physicians who then advocate for administration of drugs or use of devices for such purposes" (T.N. Gen. Assemb, 2023).}

^{"The legislature finds that healthcare providers in this state have sought to perform such surgeries on minors because the surgeries 'make a lot of money' and 'are huge money makers,' not necessarily because the surgeries are in a minor's best interest" (T.N. Gen. Assemb, 2023).}

Representatives from Georgia, Tennessee, Arkansas, and Idaho express their concerns about the quality and quantity of the efficacy of treatment for gender dysphoria.

_{"No large-scale studies have tracked people who received gender-related medical care as children to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning; on the contrary, the General Assembly is aware of statistics showing a rising number of such individuals who, as adults, have regretted undergoing such treatment and the permanent physical harm it caused;" (G.A. Gen. Assemb, 2023).}

_{"...Moreover, the legislature finds it likely that not all harmful effects associated with these types of medical procedures when performed on a minor are yet fully known, as many of these procedures, when performed on a minor for such purposes, are experimental in nature and not supported by high-quality, long-term medical studies" (T.N. Gen. Assemb, 2023).}

_{"This course of treatment for minors commonly begins with encouraging and assisting the child to socially transition to dressing and presenting as the opposite sex. In the case of prepubertal children, as puberty begins, doctors then administer long-acting GnRH agonists (puberty blockers) that suppress the pubertal development of the child. This use of puberty blockers for gender nonconforming children is experimental and not FDA-approved" (A.L. State legislature, 2022).}

_{"Among the known harms from puberty blockers is diminished bone density; the full effect of puberty blockers on brain development and cognition are yet unknown, though reason for concern is now present. There is no research on the long-term risks to minors of persistent exposure to puberty blockers. With the administration of cross-sex hormones comes increased risks of cardiovascular disease, thromboembolic stroke, asthma, COPD, and cancer" (A.L. State Legislature, 2022).}

_{"No long-term randomized studies evaluate the efficacy or safety of the use of puberty blockers for the purpose of treating gender dysphoria, and no randomized clinical trials have been conducted in the efficacy or safety of the use of cross-sex hormones in adults or children for the purpose of treating gender dysphoria" (I.D. State legislature, 2023).}

_{"Healthcare providers are also prescribing cross-sex hormones for children who experience distress at identifying with their biological sex, despite the fact that no randomized clinical trials have been conducted on the efficacy or safety of the use of cross-sex hormones in adults or children for the purpose of treating such distress or gender transition;" (A.R. Gen. Assemb, 2021).}

_{"The prescribing of puberty-blocking drugs is being done despite the lack of any long-term longitudinal studies evaluating the risks and benefits of using these drugs for the treatment of such distress or gender transition;" (A.R. Gen. Assemb, 2021).}

_{"Puberty-blocking drugs are being prescribed despite the lack of any long-term longitudinal studies evaluating the risks and benefits of using these drugs for the treatment of such distress or gender transition" (A.Z. State Legislature, 2022).}

Representatives from Georgia, Alabama, Arkansas, and Idaho are concerned with the timing of treating gender dysphoria as it aligns with puberty, and many legislatures suggest a "wait-and-see" approach to treatment.

_{"Under the principle of “do no harm,” taking a wait-and-see approach to minors with gender dysphoria, providing counseling, and allowing the child time to mature and develop his or her own identity is preferable to causing the child permanent physical damage;" (G.A. Gen. Assemb, 2023).}

_{"A significant portion of children with gender dysphoria do not persist in their gender dysphoric conditions past early adulthood;" (G.A. Gen. Assemb, 2023).}

_{"As a result, taking a wait-and-see approach to children who reveal sign of gender nonconformity results in a large majority of those children resolving to an identity congruent with their sex by late adolescence" (A.L. State Legislature, 2022).}

_{"This internal sense of discordance is not permanent or fixed, but to the contrary, numerous studies have shown that a substantial majority of children who experience discordance between their sex and identity will outgrow the discordance once they go through puberty and will eventually have an identity that aligns with their sex" (A.L. State legislature, 2022).}

_{"Gender dysphoria among children rarely persists into adulthood, with peer-reviewed research revealing that as many as ninety-eight percent (98%) of gender dysphoric boys and many as eighty-eight percent (88%) of gender dysphoria girls ultimately identify with their biological sex after passing through puberty" (I.D. State Legislature, 2023).}

_{"For the small percentage of children who are gender nonconforming or experience distress at identifying with their biological sex, studies consistently demonstrate that the majority come to identify with their biological sex in adolescence or adulthood, thereby rendering most physiological interventions unnecessary;" (A.R. Gen. Assemb, 2021).}

_{"Only a small percentage of the American population experiences distress at identifying with their biological sex" (A.R. Gen. Assemb, 2021).}  

_{"Only a small percentage of the American population experiences distress at identifying with their biological sex" (A.Z. State Legislature, 2022).}

_{"For the small percentage of children who are gender-nonconforming or who experience distress at identifying with their biological sex, studies consistently demonstrate that the majority come to identify with their biological sex in adolescence or adulthood, thereby rendering most physiological interventions unnecessary" (A.Z. State Legislature, 2022).}

Representatives from Georgia, Idaho, Kentucky, Arkansas, Nebraska, and Tennessee assert their concerns about gender dysphoria treatment due to the well-intentioned responsibility the states undertake to protect all of their citizens.

_{"The General Assembly has an obligation to protect children, whose brains and executive functioning are still developing, from undergoing unnecessary and irreversible medical treatment" (G.A. Gen. Assemb, 2023).}

_{"The legislature declares that it must take action to protect the health and welfare of minors" (T.N. Gen. Assemb, 2023).}

_{"Therefore, the state of Idaho has a compelling government interest in protecting the health and safety of its minor children from such medical interventions for the purpose of attempting to affirm or change a child’s gender expression" (I.D. State Legislature, 2023).}  

_{"Arkansas has a compelling government interest in protecting the health and safety of its citizens, especially vulnerable children;" (A.R. Gen. Assemb, 2021).}

_{"School personnel have a duty to protect the dignity, health, welfare, and privacy rights of students in their care;" (K.Y. State Legislature, 2023).}

_{"The state has a compelling government interest in protecting the health and safety of its citizens, especially vulnerable children;" (N.E. State Legislature, 2023).}

_{"...This state has a legitimate, substantial, and compelling interest in protecting minors from physical and emotional harm. This state has a legitimate, substantial, and compelling interest in protecting the ability of minors to develop into adults who can create children of their own. This state has a legitimate, substantial, and compelling interest in promoting the dignity of minors. This state has a legitimate, substantial, and compelling interest in encouraging minors to appreciate their sex, particularly as they undergo puberty..." (T.N. Gen. Assemb, 2023).}

_{"Arizona has a compelling governmental interest in protecting the health and safety of its citizens, especially vulnerable children" (A.Z. State Legislature, 2022).}

Representatives from Tennessee, Arkansas, Alabama, and Idaho indicate their concerns with the inconsistency between the treatment for gender dysphoria and the current medical standards.

_{"These experimental, irreversible, and medically unnecessary pharmaceutical and surgical interventions violate the Hippocratic oath, taken by physicians for millennia, to 'do no harm'" (I.D. State Legislature, 2023).}

_{"Some in the medical community are aggressively pushing for interventions on minors that medically alter the child’s hormonal balance and remove healthly external and internal sex organs when the child expresses a desire to appear as a sex different from his or her own" (A.L. State Legislation, 2022).}

_{"It is of grave concern to the General Assembly that the medical community is allowing individuals who experience distress at identifying with their biological sex to be subjects of irreversible and drastic nongenital gender reassignment surgery and irreversible, permanently sterilizing genital gender reassignment surgery, despite the lack of studies showing that the benefits of such extreme interventions outweigh the risks;" (A.R. Gen. Assemb, 2021).}

_{"The legislature determines that there is evidence that medical procedures that alter a minor's hormonal balance, remove a minor's sex organs, or otherwise change a minor's physical appearance are not consistent with professional medical standards when the medical procedures are performed for the purpose of enabling a minor to identify with, or live as, a purported identity inconsistent with the minor's sex or treating purported discomfort or distress from a discordance between the minor's sex and asserted identity because a minor's discordance can be resolved by less invasive approaches that are likely to result in better outcomes for the minor" (T.N. Gen. Assemb, 2023).}

Representatives from Tennessee and Alabama express their concerns with the unknown nature of the full effects of gender dysphoria treatment.

_{"The legislature finds that medical procedures are being performed on and administered to minors in this state for such purposes, notwithstanding the risks and harms to the minors" (T.N. Gen. Assemb, 2023).}

_{"This unknown, poorly studied series of interventions results in numerous harmful effects for minors, as well as risks of effects simply unknown due to the new and experimental nature of these interventions" (A.L. State Legislature, 2022).}

Representatives from Tennessee, Alabama, and Arkansas address their concerns through their declaration that minors are too incompetent to weigh the risks and benefits of gender dysphoria treatment.

_{"The legislature finds that minors lack the maturity to fully understand and appreciate the life-altering consequences of such procedures and that many individuals have expressed regret for medical procedures that were performed on or administered to them for such purposes when they were minors" (T.N. Gen. Assemb, 2023).}

_{"Minors, and often their parents, are unable to comprehend and fully appreciate the risk and life implications, including permanent sterility, that result from the use of puberty blockers, cross-sex hormones, and surgical procedures" (A.L. State Legislature, 2022).}

_{"The risks of gender transition procedures far outweigh any benefit at this stage of clinical study on these procedures" (A.R. Gen. Assemb, 2021).}

Representatives from Tennessee share their concerns about the handful of improper conduct cases between providers and patients.

_{"The legislature finds that Dr. John Money, one of the earliest advocates for performing or administering such medical procedures on minors and a founder of the Johns Hopkins Gender Identity Clinic, abused minors entrusted to his care, resulting in the suicides of David and Brian Reimer" (T.N. Gen. Assemb, 2023).}

_{"The legislature finds that healthcare providers in this state have threatened employees for conscientiously objecting, for religious, moral, or ethical reasons, to performing or administering such medical procedures" (T.N. Gen. Assemb, 2023).}

_{"The legislature finds that healthcare providers in this state have posted pictures of naked minors online to advertise such surgeries" (T.N. Gen. Assemb, 2023).}