Amid a wave of state restrictions on gender-affirming care for minors, some red states are also limiting treatment for adults.

Why it matters: Many states that enacted limits on transition-related care for minors in recent years said they were focused on protecting children.

• But three states have broadly limited or sought to broadly limit transition care for adults. Transgender rights advocates expect state lawmakers to pursue more restrictions on adults this year.
• Mainstream medical societies endorse gender-affirming care, as research shows that the care is safe and can be life-saving.

Driving the news: Ohio Gov. Mike DeWine last week announced new draft regulations that civil rights advocates say would be the strictest limits on adult transition care in the country if they take effect.

• The rules would require minors and adults to get approval from an endocrinologist, psychiatrist and bioethicist before receiving gender-affirming care.
• Providers would also have to report to the state each gender dysphoria diagnosis, any time they initiate treatment and details about the cessation of treatment, according to the draft regulations.
• DeWine, after last month vetoing legislation that would ban transition care for minors, also issued an executive order barring transition-related surgeries for minors.
• "There are things we need to do to protect children and adults, and those things go well beyond" the bill he vetoed, DeWine said during a press conference last week. The Ohio House is expected to override his veto on Wednesday.

What they're saying: Ohio's restrictions would amount to a "de facto ban" on trans care in the state, said the American Civil Liberties Union of Ohio.

• The regulations would make it very difficult for adults to access gender-affirming care, said Cam Ogden, a transgender rights activist who attends college in Ohio. They could force many smaller clinics in the state to shut down, she added.
• That could mean longer waitlists at the remaining clinics, other activists have noted.
• "I've spoken to 19-year-olds, 18-year-olds, who have spent the last two and a half years wondering whether or not their care is going to get banned," Ogden said. "They turned 18 and they finally thought they were safe, and now they're looking at another interruption in their care."

Zoom out: Lawmakers in at least four states last year introduced bills that would prohibit people as old as 26 from receiving hormone therapies or gender-affirming surgeries.

• Florida last year began requiring that adults seeking transition care sign an informed consent form, undergo psychological evaluations to continue hormone therapy, and receive all related care from a physician in person — limiting access to telehealth options or other providers with prescribing authority.
• Florida's policy, which is in effect while it's being challenged in court, has interrupted care for even the most well-connected transgender activists, The 19th reported.
• Missouri's attorney general also issued a rule last year that would have made it illegal to provide gender-affirming care to anyone in the state without confirming a diagnosis of "intense" gender dysphoria for at least three years.
• Advocates sued to block the rule, and the attorney general eventually withdrew it before it took effect.
• The state last year also barred Medicaid from covering gender-affirming care for adults, and at least eight other states have a similar restriction. Missouri also prohibits gender-affirming surgeries for people in prison.

What we're watching: State lawmakers have filed more than 150 bills targeting the transgender community in 2024 as legislative sessions begin, according to a tracker maintained by independent journalist and civil rights activist Erin Reed.

• Bills related to gender-affirming care so far would restrict care for minors, but trans care advocates expect more states to try limiting adult treatment this year.
• "We have known all along that this was never about exclusively limiting care for minors," said ACLU attorney Chase Strangio, deputy director of the group's transgender justice program. "This was always a process by which we saw states slowly encroach into access to care for adults."

The Alliance Defending Freedom, a conservative advocacy group pushing states to adopt anti-trans policies, said it's prioritizing measures that would bar minors from receiving gender-affirming care.

• "Once they reach adulthood, they can make their own decisions about this," said Matthew Sharp, senior counsel and director of ADF's Center for Legislative Advocacy.
• The American Principles Project, another conservative group, also said it's focused on policies regarding youth.
• "That being said, it's also clear that these drugs and surgeries are extremely damaging even to adults, and so we also certainly support any efforts to protect them as well as policies making it easier for them to sue in the case they were harmed," said communications director Paul Dupont.