This year, at least 12 states have passed legislation to limit or ban gender-affirming health care for young people, adding to several already on the books. In Missouri, restrictions announced last week by the state attorney general would apply to people of any age. With legislative sessions pressing on across the country, more restrictions could be on the way.

At the same time, Colorado, Illinois, Maryland, New Mexico and Minnesota have passed bills designed to shield transgender health care through legal protections, health care coverage and access. Friday, the Minnesota legislature passed protections for youth and parents who seek health care and for the providers that give it. Gov. Tim Walz, who championed the bill, says he will sign it.

"We are going to lead on this issue," said Walz, a second-term Democrat at an LGBTQ rights rally last week. "And I want to make note, not only do you belong here, you are needed here, you're part of the fabric that makes Minnesota the best place in the country to live."

Last year, California passed a similar bill, calling itself a "refuge" state for transgender youth and their families. Also this year, Oregon Democrats are proposing a constitutional amendment to protect care. Washington State and Vermont have their own protective bills.

Minnesota

Friday, the Minnesota Senate voted to pass a House-approved bill that will prevent state courts or officials from complying with child removal requests, extraditions, arrests or subpoenas related to gender-affirming health care that a person receives or provides in Minnesota.

Physicians who practice gender-affirming care in Minnesota, and families who've sought it out for their transgender children or teenagers, have said the bill will go a long way to ensure that they can continue to access treatment without fear of other states' laws. Some have said they've already seen an uptick in prospective patients from states where their options have been eliminated.

"Frequently, we will talk about gender-affirming care as life-saving health care. And we're not saying that to be dramatic," says Dr. Angela Kade Goepferd, chief education officer and medical director of the Gender Health program at Children's Minnesota. Kade Goepferd says kids who can't access care "are at significantly higher risk of worse mental health outcomes, including suicidality."

Republicans in the state legislature have opposed extending legal protections to families traveling for gender care services.

"The bill makes Minnesota a sanctuary state for so-called gender-affirming care, while simultaneously infringing on the fundamental right of parenting," said state Rep. Peggy Scott, a Republican, last month.

Maryland: Broadening Medicaid coverage

Beginning Jan. 1, 2024, the Maryland Trans Equity Act broadens the kind of gender-affirming treatments covered under the state's Medicaid plan, aligning it with care that private insurers offer.

Medicaid in Maryland already provides some gender-affirming treatments, but the list would grow to include the ability for individuals to change their hair, make alterations to their face or neck and modify their voice through therapy. Many private insurers already offer those treatments and the law gives parity to those on Medicaid.

In 2022, about 100 people received gender-affirming care through the state's Medicaid program. It's estimated that the law would increase that number by 25 individuals.

Providing gender-affirming care decreases rates of anxiety, depression and other adverse mental health outcomes, according to the Journal of the American Medical Association, a significant body of research.

Colorado: Expanded legal protections

Last week, Democratic Gov. Jared Polis signed a bill into law to ensure people in other states can come to Colorado for an abortion, to begin puberty blockers or to receive gender-affirming care without fear of prosecution. The law also extends legal protections to providers of abortions and gender-affirming care and a separate law expands insurance coverage.

"Another state's laws that seek to punish providers of reproductive healthcare, or gender-affirming care, do not apply in Colorado," said Democratic State Rep. Meg Froelich, one of the main sponsors of the legislation.

The law, which went into effect April 14, means Colorado will not participate in any out-of-state investigations involving providers or recipients of abortion or gender-affirming care. Similar to the bill in Minnesota, that includes ignoring search warrants, arrests, subpoenas, summons, or extraditions to another state, as long as the activity took place in Colorado and there is no indication those involved broke Colorado law.

The idea to make Colorado a safe haven for trans individuals was first floated last year by Colorado's only transgender state lawmaker, Democratic Rep. Brianna Titone. But Democrats decided not to take up the issue until this year.

The measures to extend legal protections and expand insurance coverage faced lengthy hearings and floor debates, but Republicans didn't have the votes to defeat them.

Cynthia Halversion, a Colorado Springs resident testified against the bill to expand insurance coverage saying she worries it opens the door to "illegitimate practices and practitioners, to perform acts that are against the constitution of the United States of America and the safety and protection of all children."

While many states have moved to restrict gender-affirming care for minors in the past year, none have so far passed laws that punish people for going to other states for treatment.

Michigan: Growing the state's Civil Rights Act

Michigan hasn't moved to explicitly protect gender-affirming care in statue. Like some other states, though, it has expanded the state's civil rights to include "sexual orientation" and "gender identity" as protected classes.

Gov. Gretchen Whitmer, a Democrat, signed a law last month to add those categories under Michigan's Elliott-Larsen Civil Rights Act, which originally protected religion, race, color, national origin, age, sex, height, weight, familial status, or marital status.

"I am so proud to be here and I am excited to put our state on the right side of history," Whitmer said as she prepared to put her signature to the bill. That move capped nearly four decades of efforts to add LGBTQ protections to state law.

The changes were adopted by the legislature's Democratic majorities over the objections of Republicans and the Michigan Catholic Conference.

"While I fully support this original intent of the Elliott-Larsen Act and understand the importance of protecting individuals from discrimination, I also believe that it is crucial to respect the religious beliefs of small business owners and employers," said Republican state Rep. Rachelle Smit.

But former Rep. Mel Larsen, a Republican who the original law is partially named for, says gay rights were always intended to be part of the protections.

Dana Ferguson is Minnesota Public Radio's politics reporter, Bente Birkeland is Colorado Public Radio's public affairs reporter, Scott Maucione is WYPR's health reporter, Rick Pluta is Michigan Public Radio's managing editor and state Capitol bureau chief, Colin Jackson is Michigan Public Radio's capitol bureau reporter and Acacia Squires is NPR's States Team editor.