Authors: Meera Rajput, JD, State Policy Analyst at the National LGBTQ Task Force and Kimya Forouzan, JD, MPH, Principal State Policy Advisor at the Guttmacher Institute
Introduction
Historically, anti-abortion and anti-LGBTQ advocates have fostered an increasingly hostile environment for diminishing meaningful access to essential health care. It is crucial to honor and ground this fight in champions who have paved the way and fearlessly advocated for rights to accessing care such as California’s Barbara Lee, who worked tirelessly to repeal the Hyde Amendment for abortion access. In the past few years, however, there has been a dramatic increase in attacks against two widely used, best-practice medically necessary forms of health care: abortion and gender affirming care. These attacks fall hardest on communities who already face systemic challenges when receiving health care and building towards economic security including Black, Indigenous and other people of color, women, LGBTQ+ individuals, immigrants, disabled people, and young people.
These attacks also come from the same lawmakers and organizations using the same harmful strategies and legislative bills to undermine access. Typically, the playbook of strategic attacks on both abortion and gender affirming care are rooted in undermining people’s bodily autonomy and their ability to make decisions about their own bodies and health care. However, the lesser known and understood connection between the attacks on both are rooted in both “parental rights” and state surveillance and criminalization of accessing each type of health care. This paper will explore the overlapping connection of these two realms when analyzing restrictions on both abortion and gender affirming care and how these strategies have fueled a growing surge of attacks on both forms of health care.
Parental Rights
The concept of “parental involvement” has been a part of the abortion rights and gender affirming care access conversation for decades. Parents already have the constitutional right to make decisions about their child’s health care and education. While the concept of parental rights and having the authority over their own children’s upbringing sounds good in theory, in practice, it has become weaponized to serve particular interests and morals of some parents over the rights of others. It has also increasingly become a tool for anti-LGBTQ and anti-abortion groups and lawmakers to diminish and restrict youth’s access to essential health care and vital education. These groups use parental rights to create environments of over-surveillance and policing of youth’s bodies and lives. It is crucial and lifesaving for young people to receive culturally competent, medically and scientifically accepted care, and be able to make informed decisions with their providers and health care teams.
Parental rights have been utilized to attack access to both abortion and gender-affirming care. Gender affirming care is a model that includes a full spectrum of services including “medical, surgical, mental health and non-medical services.” The goal of treatment is to support and affirm an individual’s gender identity and align a person’s body with that identity. No two individuals will have the same experience with their journey in seeking and receiving gender affirming care; it is a highly individualized process. For youth, gender affirming care typically focuses on social transition, which includes both the use of pronouns and/or name and dressing in a way that fits their gender identity. However, as puberty approaches, a young person may consider puberty blockers that pause, not block the development of puberty, hormone replacement therapy more geared towards late aged teenagers and surgeries, although extremely rare for a minor to undergo surgery. Most legislation and references to gender affirming care include this wide spectrum of care, and the goal is to be as explicit and clear as possible when discussing this care.
Parental Rights in the Abortion Context
Since the overturning of Roe v. Wade, the scope of parental involvement has grown to deny young people access to abortion care in new and increasingly limiting ways. Currently, 38 states require parental involvement in a minor’s decision to have an abortion. Similarly, in almost all cases, parental consent is required for transgender, nonbinary and gender expansive youth to receive gender affirming care. However, since more than half of states have some form of restriction or ban on gender affirming care, most youth cannot receive the care they need, regardless of their parent’s support.
Although the majority of states currently have parental right requirements in place, their presence throughout the country has increased over the years, as bills seeking to establish parental involvement in a minors’ abortion have become more accepted. As acceptance has grown, advocates against sexual and reproductive health and rights (SRHR) have pushed to take parental involvement laws even further. For example, some states have begun to consider measures that would completely eliminate the option of judicial bypass, or the process through which a young person can get permission from a judge to receive abortion care in lieu of their parents. In May, Florida’s Fifth District Court of Appeals issued a ruling that the state’s judicial waiver statutes were invalid and requested that the Florida Supreme Court confirm that these statutes violate parents’ Fourteenth Amendment rights. Although young people in Florida can still access judicial bypass in some limited situations, the option has become much less accessible for most youth. Other states, such as South Carolina, have attempted to eliminate access to judicial bypass completely through proposed legislation.
Additionally, states have begun to signal the desire to insert parental involvement into other forms of SRHR, such as contraception access. Over the last two years, states have increasingly introduced bills that would require parental notice or consent for contraception, as well as bills that broadly call for “parental rights” in the healthcare context. For example, states like Idaho and Tennessee have recently enacted bills that would require parental involvement in young people’s access to nonemergency health care, implicating access to contraception. Further, in March 2024, the 5th Circuit Court of Appeals upheld a lower court ruling that requires Texas clinics receiving federal Title X funding to obtain parental consent before providing prescription contraceptives to minors. Prior to this ruling, Title X clinics were a lifeline for young people in Texas who were seeking free and confidential access to contraceptives.
Anti-abortion advocates have also gone even further by attaching civil and criminal penalties to those who may help a young person access the care that they need, attempting to shut off all avenues through which they may access care. An emerging type of legislation, abortion support bans, have been enacted (and partially blocked) in two states, Tennessee and Idaho and introduced in several others. Abortion support bans assign civil or criminal liability to non-parent adults who help minors travel out of state for abortion care. These bans have a significant impact on abortion funds and practical support organizations, creating a climate of fear and hostility that works to deter young people from seeking abortion care. Additionally, a bill introduced in Montana in 2025 sought to establish similar penalties for helping anyone travel for care, regardless of age, and including the pregnant person themselves in the potential for liability. This demonstrates the reality that restrictions on young people’s access to care are often just the first step in restrictions that will ultimately be tested for people of all ages.
Forcing parental involvement in reproductive health care decisions can often deter young people from accessing the care they need, and without alternatives like the judicial bypass process or support from abortion funds and practical support networks, can completely shut them off from care. When it comes to abortion, minors who can safely do so already involve a parent in their decision.
Furthermore, young people already face significant barriers in accessing reproductive health care. For example, a Guttmacher study found that 54% of adolescents delayed expenses or sold something to help cover the costs of the abortion, compared with 46% of adults. Additionally, 70% of adolescent respondents wanted to have their abortion sooner. Among those adolescents, 19% did not know where to get their abortion, compared with 11% of adults, and 57% of adolescents who wanted their abortion sooner reported not knowing they were pregnant, compared with 43% of adults. These statistics are even more devastating, knowing abortion is lifesaving for people with reproductive health issues such as fibroids, polyps, and other structural issues that can lead to infertility, miscarriage and other complications.
Parental Rights in the Gender-Affirming Care Context
Unlike youth abortion access, there is no current judicial bypass or equivalent process for youth to bypass parental consent for receiving gender affirming care, even though research has shown that minors have some degree of autonomy that grows as they mature. Advocates for youth care, instead, focus on why parents should be involved in their child’s treatment. When parents and other trusted people in youth’s lives support a youth’s journey in exploring gender whether that is social transition- wearing clothes and/or using pronouns in a way that fits their gender identity or medical treatment such as puberty blockers that pause not block puberty, they help their child live authentically, safely and healthily in their own bodies. It can also help save youth’s lives- youth who receive the proper gender affirming care treatment they need, reduced the risk of suicidality, in some cases by 70%. However, in many cases where parents do not provide affirmation and support for their child’s transition journey, youth are left with little options to receive the care they need. Care that is misconceived as immediate and dramatic medical treatment, when in reality is a cautious and gradual process carefully executed between the patient and provider.
Another important reality is that this care is highly utilized by intersex people. Most care bans carve out “exceptions” for intersex people, but those exceptions focus on intersex surgeries for infants, done without their knowledge or consent. In practice, these laws actually harm intersex people by allowing these unnecessary surgeries to occur and cutting off the ability for intersex people to receive other forms of gender affirming care that is crucial for their body’s functioning. Additionally, intersex people, just like other LGBTQ+ people who can get pregnant, need meaningful access to abortion. However, intersex individuals face uniquely challenging barriers including misgendering, discrimination, and a misunderstanding of the specialized care needed, compounded by restrictive abortion bans.
This idea of “aiding and abetting” a minor to get their health care is also seen in the gender affirming care space, specifically applied to parents and providers. Eight states have vague language that addresses “aiding and abetting” minors from receiving care. In reality, this restricts providers from not only giving gender-affirming care but can include offering referrals or medical records to other physicians, discussing out-of-state treatment options, refilling prescriptions, or even running lab tests.
Indiana has an aid and abet provision in their law, which lawmakers tried to repeal, but were unsuccessful in doing so. One doctor in the state acknowledged that this type of provision is extremely dangerous: it can delay care, cause psychological harm and prevent physicians from sharing critical information about treatment including the potential for different medication to interact with treatment. Additionally, Ohio has recently introduced a bill that says “affirming a child’s sex does not qualify as abuse or neglect,” does not conflict with the best interests of the child, nor does it create an unsafe environment for the child. LGBTQ+ activist organization Equality Ohio has highlighted the extreme harms this bill would create including making conversion therapy an acceptable practice, threatening licenses for providers, teachers and therapists who support these children and increasing the risk for abuse, trauma and victimization of children in the state. What’s even more extreme is that Florida enacted a law that would let children be removed from their parents’ custody if they allowed their children to receive gender affirming care. This directly attacks those parents who simply want to support their child’s journey and access to this care.
These laws also disregard the reality that parents have differing rights and interests in their children’s upbringing and strongly favors traditional and strict parenting methods that may not be in the children’s best interests. It also does not reflect the reality that youth want to involve their parents when they are supportive; they do not involve them if there is a risk of violence or abuse or the fear of being kicked out. While lawmakers claim that parental right laws protect parents’ ability to decide for their children, it has the opposite effect. Its typically overly broad language gives parents ultimate decision-making power, usually based on their own morals and beliefs, that can have devastating consequences for the health and safety of youth.
Just like in abortion cases, youth who are seeking gender affirming care in restricted states must weigh their options. If they live in a restricted state, they may be forced to travel to a state where they can receive care. However, it is not that easy, especially for young people. The cost and time to travel alone can act as barriers to receiving care in another state, especially when the care requires multiple in-person appointments. For example, a 17-year-old girl named Veronica traveled from Iowa to Minnesota to receive the gender affirming care she needed, having to travel every few months for her puberty blocking shots. Like Veronica, those who have to travel out of state to get the care they need, report traveling significantly long distances and having to cover exorbitant costs for airfare, gas, lodging and parents’ lost wages. Some families also reported that they had no choice but to relocate to ensure their child got the care they needed.
Overall, while the parental rights doctrine on its face seems like common sense protection of children, it can create situations where youth lose access to care that can make them whole, healthy and ultimately safe.
State Surveillance & Criminalization
Although both abortion and gender-affirming care are safe and trusted by major reputable medical associations, the stigma around them has led to increased intertwinement with criminalization and state surveillance. Major medical and mental health organizations such as the American Medical Association, the American Academy of Pediatrics, the American Psychological Association, the Endocrine Society and more believe gender affirming care is safe, effective and medically necessary. In fact, gender affirming care is also used by cisgender people, including procedures like cosmetic surgeries and hormone replacement theory for precocious puberty and other widely known conditions. For example, procedures like breast reduction surgery, hair removal for hirsutism in women and hormone replacement therapy for menopause are forms of gender affirming care. These forms of care are just “health care” and it is not attached with the social stigmatization transgender, nonbinary and intersex people face when accessing the same exact care that affirms one’s gender identity. A doctor from Indiana also acknowledged that the kind of restriction on gender affirming care is unheard of in other areas of medicine, such as cancer treatment, heart disease, or other specialities. Similarly, well-established evidence demonstrates that abortion is safer than many common medical procedures, such as wisdom teeth removal and colonoscopies. The difference is the pervasive cloud of stigmatization over gender affirming care and abortion, not the forms of health care themselves.
Despite this, 27 states have enacted laws and policies that limit youth’s access to gender affirming care. 40% of trans youth (ages 13-17) live in one of these restricted states. Just in this past year, the Supreme Court upheld a Tennessee state law that banned gender affirming hormone therapies for those under 18 in the state in U.S. v. Skrmetti. Similarly, 13 states have total abortion bans in place currently, and an additional 28 states have bans based on gestational duration that fall somewhere between six weeks and viability.
Criminal Penalties for Care
While gender-affirming care access has been deeply impacted by Skrimetti, the battle to decriminalize gender affirming care continues in the lower courts- where 17 different states have filed lawsuits to challenge the bans and restrictions on this care. Montana’s ban on care for minors was struck down by a state district court in May 2025. The court ruled that the state’s interest in upholding the ban was political and ideological- to block transgender expression, which was not sufficient enough to uphold the ban. Yet in Arkansas, following Skrmetti’s decision, the Eight Circuit Court of Appeals rejected a challenge to their gender affirming care ban. When access to medical care such as gender affirming care is left to the whims of politicians and judges with strong ideological and political beliefs, the people who need the care and face the most barriers are harmed the most.
Many states have also enacted laws that not only restrict gender affirming care but impose harsh penalties to criminalize it. These laws largely focus on young people. This has created an increasing chilling effect that leaves providers fearful of adverse consequences, such as loss of professional licenses, legal action including monetary fines, and civil and criminal penalties. For example, in Alabama, providers can face a felony offense of up to 10 years in prison and a fine of up to $15,000 for providing gender affirming care. In Arkansas, not only is the care banned; providers are unable to make referrals to other providers that can administer care for minors. And in nearly all states that have a ban, state licensing boards can take disciplinary action against health care providers, including revoking medical licenses.
Many states also allow individuals to bring private civil action against the medical provider for damages. For example, Mississippi goes even further and allows the right to bring civil suits against “any facility, individual, or entity” that “knowingly engage in conduct that aids or abets the performance or inducement of gender transition procedures” to minors. What’s more is that the ability to bring a lawsuit lasts up to 30 years.
These efforts at criminalization nearly identically mirror those in the abortion context. Anti-abortion laws increasingly target patients, providers, abortion funds, and others who assist in abortion care with criminal penalties. Since Dobbs, the case that overturned the constitutional right to abortion, these laws also often target “aiding and abetting” abortion care, a tactic that anti-abortion and anti-LGBTQ lawmakers are using in both spaces. Although criminalization of pregnancy outcomes is not new, states have ramped up efforts to criminalize both abortion providers and patients in the last several years. For example, a recent South Carolina bill, SB323, sought to assign criminal penalties to a wide array of actions related to providing, receiving, and aiding in abortion care. It also tied these penalties to parts of the state code that govern homicide prosecutions, subjecting individuals to felony charges, as well as the potential of up to 30 years in prison, for their involvement in abortion care.
State Surveillance
Controlled Substances Laws
State surveillance mechanisms have aided opponents of abortion and gender affirming care in criminalizing patients, providers, and those who aid or assist an individual in seeking these forms of care. In particular, providers of both abortion and gender-affirming care have continued to provide care to those who need it with the protection of shield laws.The provision of this care through shield laws demonstrated the resiliency of these providers, who have increasingly become targets of violence and harassment. However, as shield laws have come under growing attacks, providers of both abortion and gender-affirming care have been targeted via various, existing state surveillance mechanisms related to prescription drugs.
For example, Louisiana, a state with a total abortion ban, enacted a law requiring that mifepristone and misoprostol, the medications used for medication abortion be listed as controlled substances in their state in 2024, in part to place added pressure on shield law providers. In the following year, several states introduced similar provisions, seeking to add both greater criminal penalties to the possession or distribution of the medication, as well as to leverage the existing controlled substances reporting system to exert greater surveillance of providers.
This again mirrors threats to gender-affirming care. Testosterone is a Schedule III controlled substance under the federal United States Controlled Substances Act. This means it is more strictly regulated than other prescription drugs- a doctor’s prescription is required and that prescription is typically only good for 6 months at a time. People on Medicaid and private coverage can only typically get the prescription for 30 days at a time, which requires monthly pharmacy visits. The restrictions on testosterone create significant barriers to care and increase the likelihood of being criminalized and surveilled for something as basic and necessary as hormone therapy.
Furthermore, just like the increased surveillance and criminalization of abortion providers, gender affirming care physicians have been under the microscope. In 2024, Texas Attorney General Ken Paxton sued Dallas-based physician Dr. May Chi Lau for allegedly providing gender affirming care to 21 youth, making it the first time an attorney general brought a suit against an individual doctor for allegedly violating a gender affirming care ban. Only two weeks later, Paxton sued another provider, Dr. Hector M. Granados, for allegedly providing gender affirming care to nearly two dozen youth. Texas has a gender affirming care ban for those under 18 since 2023. Just in October 2024, Dr. Lau surrendered her Texas medical license and moved to Oregon. Dr. Granados’ suit was dismissed in September 2025 having found that he stopped providing gender affirming care to youth before the ban took effect. As more anti-abortion and anti-LGBTQ lawmakers are emboldened to directly attack individual providers for administering essential health care, many youth will go without the care they need.
Drug Labeling & Other State Surveillance Mechanisms
Drug labeling also has the potential to be utilized to further leverage the attacks on shield law providers who are providing abortion care by allowing state officials to directly track shield providers who provide care to patients in states with abortion bans. As a result, 7 protective states (California, Colorado, Maine, Massachusetts, New York, Vermont, Washington) thus far have enacted legislation that would allow facility names, as opposed to individual providers’ names, be listed on labels for medication abortion prescriptions. This proactive and protective measure can also apply to medication for gender affirming care. For example, Vermont allows for the removal of provider and pharmacist names for non-controlled substances for gender affirming care; however, this does not apply to testosterone, which is a controlled substance. While this proactive step can help lessen the threat to shield law providers who are providing abortion care, its effects are limited for those providing gender-affirming care due to testosterone’s classification as a controlled substance on the federal level.
State surveillance has also grown to become a threat to abortion patients. Although instances of criminalization currently often arise from a report by another person, surveillance has been utilized in law enforcement settings in connection with reproductive rights. For example, in 2025, police used license plate detection software to track down a woman who had recently received abortion care. The threat also continues to grow around other forms of surveillance technology, such as digital IDs. In response to threats of state surveillance in pregnancy criminalization, proactive states have taken steps to protect data privacy for reproductive health care information. In 2025, 24 states introduced 50 bills that would shore up data privacy protections related to reproductive health care, and 4 of those bills were enacted.
Mandatory Abortion & Gender Affirming Care Reporting
Additionally, in the abortion context, state requirements on abortion reporting pose a significant threat to patient privacy, especially in light of the current policy climate around criminalization of abortion and pregnancy outcomes. Currently, 45 states and the District of Columbia have some form of mandated abortion reporting. Despite the fact that abortion reporting requirements have been widely accepted throughout the country, these laws have increasingly been leveraged to cause harm to patients. While individual data, such as patient names, are not included in these reports, the threat of this form of state surveillance is still present. For example, the Attorney General of Indiana recently pushed for disclosure of individual terminated pregnancy reports, citing the purpose of law enforcement. These examples of state surveillance raise particular threats of post-Dobbs. Guttmacher data shows that in the first half of 2025, 74,490 patients traveled out of state to obtain abortion care. For patients that return home to a state with a total ban or other abortion restrictions, state surveillance mechanisms are a significant threat, especially as threats of criminalization continue to grow.
The threats that arise from mandatory abortion reporting and medical records are mirrored in the gender-affirming care space. In April 2025, U.S. Attorney General Pam Bondi released a memo asking the Department of Justice (DOJ) to investigate healthcare providers and pharmaceutical companies which provide gender-affirming care. Later in October, California Attorney General Rob Bonta, along with 15 AGs filed an amicus brief asking a PA district court to limit the DOJ’s subpoena that allows for the release of private patient records related to gender affirming care at Children’s Hospital of Philadelphia (CHOP). These types of requests for information such as patient names, home addresses, and social security numbers for young people are clear violations of privacy and increase the possibility of targeted criminalization.
Additionally, a Texas directive launched by Governor Greg Abbott in 2022 directed The Department of Family and Protective Services to investigate parents who help provide gender affirming care to their children and consider their actions child abuse. Although civil rights groups such as Lambda Legal and ACLU were able to successfully block this directive in court, Texas still has an extreme ban on access, and many are unable to receive the care they need as a result. As bans on both abortion care and care for transgender and nonbinary communities surge, we will likely see drastic adverse effects on children’s ability to grow, thrive and feel safe in their own bodies.
Ultimately, these similarities demonstrate the ultimate end goal of those opposed to sexual and reproductive health & rights: criminalization of patients, providers, and helpers who assist people in accessing the lifesaving care they need.
Conclusion
The similarities that arise from the areas of “parental rights” and criminalization and state surveillance demonstrate that the overlap between attacks on abortion and gender-affirming care go much further than the overarching concept of attacks on bodily autonomy. Those opposed to both forms of necessary, life-saving care use similar arguments and tactics to attack its existence and its widely accepted classification as the medical standard of care. Those who work tirelessly to embed state laws that weaponize the fear of criminalization also use parental rights as a scapegoat to prevent youth from getting the care they need and use these tactics as a blueprint to perpetuate anti-LGBTQ sentiment. The fight for a world free of stigma and affirming of the care that people need must encompass both abortion and gender-affirming care.
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