CNN  — 

This year has been record shattering for anti-LGBTQ legislation, with particular scrutiny on gender-affirming health care access for transgender children and teenagers. Nineteen states have passed laws restricting it — but not all bans are the same.

While some states have enacted laws that can punish health care professionals who provide gender-affirming treatment to minors with prison time, others have built in limited exceptions for minors to continue medication-based or nonsurgical forms of care, according to a CNN analysis of data from the Movement Advancement Project, a nonprofit think tank that advocates for LGBTQ rights. These wide-ranging restrictions have created a complicated legal landscape for trans people to maneuver. Several of the bans face legal challenges from health care providers and civil rights organizations.

Gender-affirming care is medically necessary, evidence-based care that uses a multidisciplinary approach to help a person transition from their assigned gender — the one the person was designated at birth — to their affirmed gender, the gender by which one wants to be known.

Transgender medical treatment for minors continues to be a political target, especially in red states, and has quickly emerged as a key issue leading up to the 2024 election. Blue states have responded by protecting access to care.

The Human Rights Campaign, the largest LGBTQ advocacy group in the US, declared the first-ever national state of emergency for the LGBTQ+ community Tuesday.

The state of gender-affirming care in the US

All but three of the 19 bans on gender-affirming care were enacted this year, MAP data shows.

“A risk of going to jail or being prosecuted for providing care, it’s going to be a huge disincentive,” said Elana Redfield, Federal Policy Director at the Williams Institute, a think tank at the University of California, Los Angeles School of Law researching sexual orientation and gender identity law and public policy.

“If you were to provide the care that is recommended by the American Medical Association or the American Psychological Association, then that would be deemed unprofessional conduct, and you could lose your medical license,” Redfield said.

The AMA, the largest professional medical association including more than 270,000 doctors, opposes restrictions on transgender medical care and deems medical and surgical treatment for gender dysphoria medically necessary. Though transgender adults may seek surgical interventions, such procedures are not typically done on children and many health care providers do not offer them to minors.

Iowa, Mississippi, and Indiana when it goes into effect in July, ban people from “knowingly” conducting in a way that “aids or abets” in minors getting gender-affirming care. In Iowa and Indiana, this applies specifically to health care professionals. In Mississippi, however, this extends to anyone involved — including parents. The Mississippi law also allows doctors to be sued for providing gender-affirming care within a 30-year statute of limitations.

Montana’s law will prohibit the use of state properties or resources to knowingly promote or advocate for social transitioning — which can include the adoption of new names, pronouns or appearances — when it goes into effect in October. Montana is the first state to specifically target social transitioning, according to MAP.

Several states include exceptions for minors who have already been receiving gender-affirming care when bans were signed into law. However, most of the exceptions are limited. In South Dakota, minors with existing hormone prescriptions prior to July 1, 2023 can continue receiving treatment through the end of the year — with the expectation that medical providers will “systematically reduce” their prescription over that period. And in Kentucky, minors are only allowed to receive care through the end of June, when the law goes into effect.

Unlike the other 18 states, Arizona, which prohibits gender-affirming surgeries for most minors,  does not place restrictions on other gender-affirming care such as hormone treatments or puberty blockers.

A record-year for anti-trans legislation heading into 2024 election

All of the 19 states targeting gender-affirming care have state legislatures under Republican control, except for Nebraska’s, which is nonpartisan.

Republican lawmakers say these measures are intended to protect children and have described gender-affirming procedures as “child abuse.” Democrats argue that Americans’ right to health care should be protected and have pointed to medical evidence that gender-affirming care is clinically appropriate.

Presidential candidates have been vocal about their stances on the issue. Former President Donald Trump said he would make gender-affirming surgeries illegal if elected to the White House again. Republican candidate and Florida Gov. Ron DeSantis has signed bills banning gender-affirming care for minors in his state. President Joe Biden condemned Florida and suggested federal laws be passed to protect access to trans health care.

The AMA and LGBTQ advocates stress that gender-affirming care can be life-saving treatment for trans youth. Transgender and nonbinary youth are twice as likely to have attempted suicide compared to their cisgender peers, according to a 2022 survey by the Trevor Project, a suicide prevention and crisis intervention organization for LGBTQ youth.

At least 10 other states and the District of Columbia have passed “shield” laws since last year that protect access to care. Colorado’s Gov. Jared Polis, a Democrat, has enacted laws making the