Lawmakers in at least eight states used the last two months of 2022 to prefile anti-transgender bills ahead of state legislative sessions convening this month — setting up another year of statehouse battles over trans rights, while targeting health care for trans adults in new ways.

Most states moving early on anti-trans bills focused on banning gender-affirming care for trans youth, while others have proposed banning care for adults, according to data from the Equality Federation, a coalition of state LGBTQ+ organizations, and a review of state bills by The 19th. 

So far, efforts to restrict health care for transgender adults, either directly or through insurance exclusions, stand out as the new ground being broken ahead of 2023 legislative sessions. Education will be another crucial policy arena to watch after so-called “Don’t Say Gay” laws, and other bills impacting LGBTQ+ students, went into effect across the country last year. 

Identifying which states are prioritizing anti-LGBTQ+ legislation, regardless of whether those bills ultimately fail, is important because a pattern has emerged in the past few years: Those same states have also made new and exploratory efforts to implement anti-trans policies outside of their legislatures. Texas and Florida are key examples. Actions from Texas’ governor and Florida’s state-appointed medical board enabled swifter restrictions and put greater political pressure on providers of gender-affirming care for trans youth. 

Forty-three states will convene their legislative sessions in January. Here are the states that got a head start on anti-trans legislation before the new year. 

South Carolina

Republicans in South Carolina have introduced a bill to ban gender-affirming care for anyone 21 years old or younger. The state further proposes that requirements already typical for trans adults seeking gender-affirming care are codified into law. 

Under the current version of the bill, trans people over 21 trying to get gender-affirming care in South Carolina would need a referral from their primary care doctor and a psychiatrist who finds that such care would treat their gender dysphoria. A referral from a primary care doctor or letter from a mental health professional is already standard for many adults seeking gender-affirming care, especially to get those procedures covered by insurance. Although South Carolina’s proposal wouldn’t change much, it still comes as some trans adults worry that their health care will be increasingly targeted by state-level restrictions. 

Lawmakers in South Carolina, where both chambers of the state legislature are Republican-controlled, have proposed blocking public funds from being “used directly or indirectly” for gender transition procedures, without specifying whether such a restriction applies to procedures for only trans youth. The same bill also mandates that teachers and school employees out transgender students — or any student suffering from gender dysphoria — to their parents. 

Texas

Lawmakers in Texas, another state where Republicans hold a trifecta of power in the governorship and in both legislative houses, filed 10 anti-trans bills in the last two months. The bills are focused on gender-affirming care, in addition to one bill that aims to prohibit schools from letting trans students play sports that match their gender identity. Republican lawmakers have proposed making gender-affirming care for minors a prohibited practice for physicians, marking it as a second-degree felony, and labeling the prescription of puberty blockers and hormone therapy to minors as child abuse. 

Like in South Carolina, lawmakers in Texas have proposed a bill that would prohibit state funds from being used for health benefits covering gender-affirming treatments — without specifying age requirements for that restriction. 

One bill slated for Texas’ legislature to take up later this month stands out, since it bars gender-affirming care for minors while carving out an exception for youth who had already begun hormone treatment or puberty-blocking medication prior to the bill’s potential effective date. 

Arizona

A prefiled Arizona bill directs school district employees to address all students under 18 years old using pronouns that match their sex assigned at birth, effectively ordering the misgendering of transgender or nonbinary children unless a parent provides written permission. The Republican Party controls both chambers of the state legislature, although the state has just elected a Democrat for governor — and some GOP lawmakers in the state put up resistance against their own party when debating anti-trans bills last year. 

Oklahoma

Oklahoma, which convenes its GOP-controlled legislature in February, will consider a bill to ban gender-affirming care for anyone under 21 years old — an effort that failed in the state in 2021. Notably, lawmakers have also brought a bill that would ban physicians from administering any gender-affirming care to transgender adults who are under 26 years old and ban them from referring their patients to receive such care. The legislation also aims to keep gender-affirming care from being covered through the state’s Medicaid program. Such a prohibition has precedent, as multiple states exclude trans health care coverage from their Medicaid policies.

Doctors found guilty under Oklahoma’s proposed bill, if it became law, would be guilty of a felony for administering medical care to adults. The far-reaching legislation seeks to block care at a higher age than most other states have considered. 

“We haven’t seen these types of bills in previous years. This is a startling new evolution of what these bills can be,” said Vivian Topping, director of advocacy and civic engagement of the Equality Federation. 

Oklahoma lawmakers also prefiled a bill setting terms on the use of names and pronouns. Like the bill in Arizona, it effectively asks school adults to misgender trans and nonbinary students by default until informed otherwise by a parent. It also sets terms on the use of names, saying that minors must be addressed by names found on or derived from their birth certificate unless parents provide written consent. Following the format of Florida’s “Don’t Say Gay” bill, the legislation would also ban classroom instruction on sexual orientation and gender identity from kindergarten through sixth grade.  

Missouri

In prefiled bills that seek to ban gender-affirming care for trans youth, Missouri lawmakers aim to penalize any adult who “coerces” a minor into undergoing gender-affirming care. The bill would classify this as child abuse or neglect — a felony in the state. The proposal is unclear on how it defines coercion of gender-affirming care for minors. Republicans have also reintroduced a bill from 2020 that would report parents to the state for obtaining such care. The state’s legislature, which is controlled by Republicans in both chambers, has also proposed a ban on public funds being used in gender transition procedures for minors.  

Tennessee

Tennessee’s bill to ban gender-affirming care for trans youth makes a point to tie the provision of such care to Planned Parenthood clinics, which are key resources of hormone therapy and other treatments for many transgender adults. Republicans control both of the state legislature’s chambers, and the state’s GOP governor — who has previously signed anti-trans bills into law — called for an investigation last fall into gender-affirming care for minors at Vanderbilt University Medical Center. 

Tennessee lawmakers are also backing an effort to block state funds from being used in health plans or insurance policies, offered through the government, that provide gender-affirming care — without specifying if the policy only applies to minors. 

Utah

Lawmakers in Utah, home to a Republican trifecta, have prefiled bills to ban gender-affirming care for trans youth.  

Republican Gov. Spencer Cox of Utah last year vetoed a bill that aimed to bar transgender students, especially trans girls, from competing in school sports that align with their gender identity. 

Virginia

One bill has been prefiled in Virginia to ban gender-affirming care for trans youth, ahead of the state’s legislative session. The state is one of few on this list with divided party control of its state legislature. 

Kentucky

Kentucky, which began its new legislative session this week, has one school bathroom bill in committee that would allow families to sue if their child encounters a trans student while using the restroom. 

Other states are still drafting bills restricting gender-affirming care for trans youth, although they have yet to formally introduce the legislation. Montana lawmakers are in the process of drafting multiple such bills, and New Hampshire lawmakers are still drafting one, currently on file as LSR0071.  

Topping, as well as Corinne Green, policy and legislative strategist for the Equality Federation, don’t want trans people to panic in response to the legislation ahead for 2023 and the evolution of more bills that are targeting adults. 

“We are still really early in the year,” Topping said. “Who knows what happens with these bills as we move forward. The one thing that we do know is that when we have shown up in the past, when we have shown up in state capitols, which trans people and those who love us always do, we have been able to beat these bills.”