The laws governing gender-affirming care for minors now vary dramatically by state. As of late 2025, 27 states restrict or prohibit medical treatments such as puberty blockers and hormones for anyone under 18, while 17 states and Washington, D.C. have enacted shield laws protecting access. The U.S. Supreme Court’s June 2025 ruling in United States v. Skrmetti confirmed that states may impose these bans, and federal policy has shifted to cut off Medicaid and CHIP funding for the treatments. Where a family lives now largely determines what care is legally available.
The State-by-State Divide
The country is split. Twenty-seven states have passed laws or policies that prohibit health care providers from prescribing puberty blockers or hormones to treat gender dysphoria in patients under 18. Every one of these state laws also bans surgical interventions for minors. Penalties fall on providers rather than parents or the minor. In some states, providing prohibited treatment is a felony; in others, the consequences are limited to professional discipline such as license suspension or revocation.
The specifics matter. Some bans include a grandfathering exception for minors who were already in treatment when the law took effect, letting them continue under a physician’s care. Others cut off all treatment immediately. A handful of states also reach across their borders by restricting telehealth prescribing from out-of-state providers, closing a workaround some families had used.
On the other side of the divide, 17 states and Washington, D.C. have enacted shield laws intended to protect families and providers involved in gender-affirming care. Eight states expanded or enacted new shield law provisions in 2025 alone. These laws typically block state cooperation with out-of-state investigations and prosecutions tied to gender-affirming care, refuse to honor out-of-state subpoenas or arrest warrants in such cases, and prohibit state agencies from assisting other states’ enforcement. Some also protect providers from losing their licenses based on care delivered to patients from ban states.
Social transition, which involves non-medical changes such as different clothing, hairstyles, or pronouns, is not restricted anywhere. Every state ban targets medical and surgical interventions.
What the Supreme Court Decided in Skrmetti
On June 18, 2025, the Supreme Court decided United States v. Skrmetti in a 6-3 ruling that upheld Tennessee’s law banning puberty blockers and hormones for minors when prescribed to treat gender dysphoria.1Supreme Court of the United States. United States v. Skrmetti, No. 23-477
The federal government had argued that Tennessee’s law amounted to a sex-based classification requiring heightened judicial scrutiny under the Equal Protection Clause. The Court disagreed. Chief Justice Roberts, writing for the majority, held that the law classifies based on age and medical use rather than sex, because minors of any sex are equally barred from receiving these treatments for gender dysphoria. That put the law under the more lenient rational basis standard, which it easily survived. The Court accepted Tennessee’s legislative concern that these treatments could expose minors to irreversible effects including potential sterility as a rational basis for the restriction.1Supreme Court of the United States. United States v. Skrmetti, No. 23-477
The ruling did not require any state to ban gender-affirming care. It held only that the Constitution does not prevent them from doing so. Practical effect: legal challenges to the 27 existing state bans lost their strongest constitutional argument, and bans that had been temporarily blocked by court injunctions are likely to take full effect as those cases are reconsidered under the more deferential standard.
Federal Policy and Funding
Federal policy has moved sharply against these treatments for minors. On January 28, 2025, the President signed an executive order titled “Protecting Children from Chemical and Surgical Mutilation,” which established as official U.S. policy that the federal government will not fund, sponsor, promote, or support medical transition for anyone under 19. The order directed all federal agencies to rescind policies relying on WPATH guidance and instructed the Secretary of Health and Human Services to take regulatory action across Medicaid, Medicare, and other federal health programs.2The White House. Protecting Children from Chemical and Surgical Mutilation
The largest regulatory shoe to drop is a proposed rule from the Centers for Medicare and Medicaid Services, published in December 2025, that would prohibit federal Medicaid and CHIP funding for what the rule terms “sex-rejecting procedures” for anyone under 18. Puberty blockers, hormones, and surgical procedures intended to align a minor’s appearance with a gender identity different from their sex at birth would all be covered by the prohibition. Mental health treatment for gender dysphoria would remain reimbursable. The public comment period closed in February 2026, and if finalized, the funding cutoff is expected to take effect on October 1, 2026.3Federal Register. Medicaid Program – Prohibition on Federal Medicaid and CHIP Funding for Sex-Rejecting Procedures Furnished to Children
Insurance nondiscrimination protections at the federal level are effectively dormant. The Biden administration’s May 2024 rule under Section 1557 of the Affordable Care Act, which prohibited insurers receiving federal funds from categorically excluding gender-affirming care, was blocked by federal court injunctions before it could take full effect.4Federal Register. Nondiscrimination in Health Programs and Activities Those injunctions remain in place, and the current administration has rescinded related guidance rather than defending the rule.5U.S. Department of Health and Human Services. Rescission of HHS Notice and Guidance on Gender Affirming Care The federal prohibition on categorical insurance exclusions is not currently being enforced.
Crossing State Lines for Care
The gap between ban states and shield states has produced a legally unprecedented interstate tension. A provider in a shield-law state who treats a minor from a ban state is protected under local law but could theoretically face charges if they set foot in the banning state.
For families, the practical question is whether a home-state ban reaches care obtained elsewhere. Most bans target providers rather than parents, so the direct legal exposure for a family that travels is limited. The risk is not zero. A ban state could attempt to characterize seeking out-of-state care as a form of child endangerment, particularly in a contested custody dispute. Shield laws in the treatment state are designed to blunt these efforts by refusing cooperation with out-of-state investigations, subpoenas, and warrants tied to gender-affirming care.
Parental Consent Where Care Is Legal
In states where medical gender-affirming care remains legal, treatment for a minor almost always requires informed consent from a parent or legal guardian. The parent must understand the treatment’s benefits, risks, alternatives, and long-term consequences, including effects on fertility, before authorizing care.
Disputes between parents with joint custody are handled in family court, where a judge decides based on the child’s best interests and may weigh the minor’s own views depending on age and maturity.
Some states recognize a mature minor doctrine, which allows a minor to consent to medical care without parental involvement if they can demonstrate sufficient understanding of the treatment’s consequences.6American Journal of Public Health. Minors Rights to Access Sexual and Reproductive Health Care Not all states recognize the doctrine, and even where it exists, clinicians are often reluctant to rely on it for treatments with irreversible effects. As a practical matter, most providers require documented parental consent before starting any medical intervention.
Paying for Treatment
Private insurance coverage varies widely even where care is legal. Some employer-sponsored and marketplace plans cover puberty blockers and hormone therapy; others exclude gender-affirming treatments entirely. Whether a specific plan must cover these treatments depends on state insurance mandates, which exist in some shield-law states and are absent in most ban states.
If the CMS rule takes effect in October 2026, Medicaid and CHIP will no longer reimburse for medical gender-affirming treatments for minors at the federal level. States could continue covering these services using only state funds, but few are expected to absorb the full cost. For families relying on Medicaid, this would effectively end coverage regardless of whether their state permits the care.
Out-of-pocket costs vary substantially. Puberty blockers can run several thousand dollars per month without insurance. Hormone therapy is considerably less expensive, with monthly medication costs typically ranging from roughly $30 to over $100, though lab work and office visits add to the total. Surgical procedures, when performed, can run into tens of thousands of dollars.
Gender-affirming medical treatments may qualify as deductible medical expenses on federal income taxes if they meet the IRS definition of costs to diagnose, treat, or prevent disease, rather than cosmetic procedures performed solely to improve appearance.7Internal Revenue Service. Publication 502, Medical and Dental Expenses The IRS does not specifically address gender-affirming care in Publication 502, so deductibility turns on whether the treatment is considered medically necessary rather than cosmetic. A formal diagnosis of gender dysphoria from a qualified provider strengthens the case. Medical expenses are only deductible to the extent they exceed 7.5% of adjusted gross income.