Intersex Exceptions in U.S. Laws Restricting Medical Care for Transgender Minors

Intersex Exceptions in U.S. Laws Restricting Medical Care for Transgender Minors | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Intersex Exceptions in U.S. Laws Restricting Medical Care for Transgender Minors View ORCID Profile Sara A. Mar , View ORCID Profile Gnendy Indig , View ORCID Profile Meredithe McNamara , View ORCID Profile Elizabeth R. Boskey , View ORCID Profile Katharine B. Dalke , View ORCID Profile Elizabeth Dietz , View ORCID Profile Morgan Carpenter , View ORCID Profile Cynthia Kraus , Erika Lorshbough , View ORCID Profile Quinnehtukqut McLamore , Kimberly Zieselman , View ORCID Profile Brian D. Earp , View ORCID Profile Hannah C. Wenger doi: https://doi.org/10.1101/2025.04.22.25326142 Sara A. Mar 1 The Institute for Health Research & Policy at Whitman-Walker , United States MPH Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sara A. Mar Gnendy Indig 2 Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont Medical Center , United States MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Gnendy Indig Meredithe McNamara 3 Department of Pediatrics, Yale School of Medicine , United States MD, MS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Meredithe McNamara Elizabeth R. Boskey 4 Division of Gynecology, Boston Children’s Hospital; Department of Surgery, Harvard Medical School , United States PhD, MPH, MSSW Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Elizabeth R. Boskey Katharine B. Dalke 5 Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania , Penn Medicine, United States MD, MBE Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Katharine B. Dalke Elizabeth Dietz 6 School of Life Sciences, Arizona State University , United States PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Elizabeth Dietz Morgan Carpenter 7 Sydney Health Ethics, University of Sydney School of Public Health , Australia PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Morgan Carpenter Cynthia Kraus 8 STS Lab, Institute of Social Sciences, Faculty of Social and Political Sciences, University of Lausanne , Switzerland PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Cynthia Kraus Erika Lorshbough 9 interACT , United States JD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Quinnehtukqut McLamore 10 Psychological Sciences, University of Missouri at Columbia , United States PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Quinnehtukqut McLamore Kimberly Zieselman 11 Outright International , United States JD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Brian D. Earp 12 Centre for Biomedical Ethics, National University of Singapore , Singapore PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Brian D. Earp For correspondence: hwenger{at}pennstatehealth.psu.edu bdearp{at}nus.edu.sg Hannah C. Wenger 13 Division of General Internal Medicine, Pennsylvania State University College of Medicine, PennState Health Milton S. Hershey Medical Center , United States MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Hannah C. Wenger For correspondence: hwenger{at}pennstatehealth.psu.edu bdearp{at}nus.edu.sg Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Contemporary U.S. legislation restricts hormonal and surgical interventions for transgender and gender-diverse (TGD) persons, primarily legal minors, who may need them and who voluntarily request them. We conducted a comprehensive review of all U.S. legislation from 2021 to 2024 that restricts voluntarily sought TGD-related healthcare and found explicit allowances for physically comparable, but non-voluntary interventions to “normalize” the benign bodily attributes of children with intersex conditions, or congenital variations in sex characteristics. Our findings could suggest a lack of equal regard for all individuals’ moral and legal rights to self-determination and bodily autonomy. INTRODUCTION Since 2021, 27 U.S. states have enacted legal restrictions, or bans, on voluntary medical interventions (commonly termed gender-affirming medical care or GAMC) for transgender and gender diverse (TGD) individuals, primarily legal minors (Appendix). Supporters of these bans have argued that the restrictions are necessary to protect TGD minors from potentially risky medical interventions that alter benign sexual anatomy – that is, non-diseased anatomy that does not, in and of itself, threaten the health of the individual – and allege that the minors are too young to understand or consent to such interventions, notwithstanding parental permission. Seldom acknowledged in the sociopolitical discourse about these bans are their statutory exceptions, or carve-outs, that specifically exempt – and implicitly endorse – non-voluntary, appearance-“normalizing” interventions on the benign bodily attributes of presumptively non-TGD individuals, primarily those with variations of sex characteristics (VSCs) or intersex traits (discussed further below). These interventions affect similar anatomy to GAMC, carry analogous physical risks, and are of unknown benefit. Yet, unlike GAMC for TGD minors, they are regularly performed before the child is able to participate meaningfully in the decision-making process regarding their own body. To elucidate this tension, we conducted a comprehensive review and analysis of all laws between 2021 and 2024 that limit GAMC for TGD populations in the United States, paying special attention to how sex and gender are defined in the laws and to the justifications, if any, provided for intersex-related or other exceptions to the prohibitions on GAMC. Our methodology and findings are highlighted below with full details and documentation including search strategy located in the Appendix. Background To frame our study, we begin with a brief overview of intersex and TGD populations and how they differ in certain ways, while also having some overlapping medical needs. Sex and gender are often oversimplified and inaccurately regarded as being synonymous, sometimes leading to a conflation of intersex and TGD concepts (see Appendix Table 1 for definitions). Despite considerable political contestation over the nature and implications of these categories within social and legal spheres, the complexities of sex and gender – and the experiences of persons living outside of traditional sex or gender classifications – are increasingly salient within medicine and the biological sciences.( 1 – 5 ) At birth, sex is usually recorded as female or male following visual inspection of an infant’s genitalia. For infants born with what are variously called differences of sex development, intersex traits, or congenital variations in sex characteristics (VSCs),( 6 , 7 ) their anatomical features, hormone profiles, or karyotype are judged to differ from normative biomedical criteria for the female or male sex. Though recent and reliable prevalence data are unavailable for the intersex population, it is estimated that a fraction of 1% to under 2% of babies are born with VSCs.( 8 – 13 ) In some such cases, additional medical tests may be performed before a decision is made about sex classification. Alongside biological information, this decision may be informed by social or cultural beliefs, such as perceived ideals regarding femininity or masculinity,( 14 – 17 ) which may or may not align with the individual’s future identity or values. Among more than 30 VSCs and at least 100 genes linked to development of diverse sex characteristics,( 12 ) some conditions may be associated with serious physical health risks that necessitate urgent medical intervention (see endnote 18). However, most VSCs do not portend significant physical impairment or risk of death, and any associated diverse-appearing genitalia are not inherently pathological. Still, hormonal and surgical interventions are often performed on infants and children born with benign or low-risk VSCs in an effort to conform their bodies to what is considered typical for females or males. Mostly, this is done on a non-voluntary basis before the child can consent or assent. This preempts opportunities for individuals born with VSCs, some of whom may later identify as intersex, to freely develop and express their own values and preferences about their bodies; to pursue the option of leaving their sexual or reproductive anatomy unmodified, or differently modified; and, if modification is judged desirable, to be personally informed of the risks of such “normalizing” procedures so as to weigh these against any potential benefits.( 19 – 21 ) Most infants are reared as if their birth-recorded sex accurately describes both their internal and external sex characteristics and their self-conception or experienced identity in relation to sex or gender, sometimes termed “gender identity.”( 22 ) Most people living in the U.S., whether intersex or non-intersex (i.e., “endosex”)( 23 ), have a gender identity that aligns with what is culturally prescribed for individuals with their birth-recorded sex. Such individuals are often termed cisgender or non-transgender (non-TGD). Approximately 1% experience a gender identity that differs from what is normatively associated with their birth-recorded sex.( 24 , 25 ) These individuals may be described, or may self-identify, as transgender or gender-diverse (TGD). Gender-affirming medical care (GAMC) refers to interventions that are intended to resolve felt discrepancies between physical embodiment and gender identity. These discrepancies can be highly distressing and can have a significantly negative impact on well-being if left unaddressed. For TGD individuals, GAMC may consist of hormonal and non-hormonal medications, vocal training, mental health support, fertility treatments, and/or surgeries, among other modalities. Importantly, GAMC is a common healthcare need for both TGD and non-TGD individuals (e.g., interventions to address gynecomastia in non-TGD males; see endnote 26).( 27 – 29 ) Irrespective of whether a person has been medically classified as female or male (with or without the presence of VSCs), or identifies as intersex, TGD, or otherwise, individuals of all body types and identities ought to have the equal opportunity to pursue, or to forgo, GAMC or other similar interventions on a voluntary basis, in accordance with the fundamental human rights to non-discrimination, self-determination, and bodily autonomy.( 19 , 20 ) However, legal and political processes may affect this equality of opportunity, as shown herein.( 30 – 33 ) We searched and analyzed U.S. legislation from 2021 to 2024 that prohibits voluntarily sought TGD-related healthcare and found explicit allowances for physically comparable, but non-voluntary interventions to “normalize” the benign bodily attributes of children with intersex conditions, or VSCs. As a group with practical and scholarly expertise in the fields of medicine, law, and ethics, we considered legal and ethical aspects of how U.S. jurisdictions statutorily define sex and gender and treat healthcare services that alter sexual anatomy, with a focus on categorical restrictions and exceptions. METHODOLOGY We searched for statutes across four full legislative sessions (January 1, 2021, to December 31, 2024) that restrict healthcare services for TGD individuals in all 50 U.S. states, the District of Columbia, U.S. territories, and tribal and federal jurisdictions (see Appendix Box 1 and Figure 1 for detailed search methodology).( 36 ) Statutes were assessed through sequential, independent review by two authors (SAM, HCW). For each statute, the authors identified descriptions of sex, gender, and GAMC; restricted healthcare services; stated purpose(s) for which services are restricted; exceptions to restrictions; and penalties for statutory violations. All quoted text denotes statutory language. Download figure Open in new tab Figure 1. Map of intersex and penile circumcision exceptions in U.S. laws* restricting medical care for transgender minors, 2021-2024. GAMC = Gender-Affirming Medical Care. No GAMC bans were identified in the District of Columbia, U.S. territories, or tribal and federal jurisdictions during the study period. (+) denotes a state in which a GAMC ban was enacted after a veto override. RESULTS We identified 28 U.S. states with a combined total of 30 passed or enacted statutes (i.e., bans) that restrict healthcare services for TGD minors ( Appendix Table 2 ), including 2 states (KS, TN) that passed a ban in 2 separate legislative sessions.( 37 ) Three of the 30 bans were passed by the legislature but permanently vetoed by the governor (KS, WI), leaving 26 states that enacted a ban in the study period.( 38 ) No bans were identified in the District of Columbia, U.S. territories, or tribal and federal jurisdictions. Twenty-eight of the identified 30 bans prohibit, for the purposes of “gender transition” (or a similar term), the use of medications that suspend pubertal development and/or the use of hormone therapies. Twenty-nine bans prohibit genital and/or non-genital surgeries. Fourteen bans also mention that medical and surgical care is disallowed if it affects or removes a minor’s “healthy,” “functional,” or “nondiseased” body parts, including characteristics “typical” for their biological sex. None specifies the party responsible for making such determinations. All 30 bans denote statutory exceptions, or instances in which restricted care is permitted ( Figure 1 below; Appendix Tables 2 - 3 ). Twenty-nine of the 30 bans contain an exception for interventions on individuals with VSCs; Tennessee’s 2021 ban does not include such an exception, but this statute was superseded by a 2023 ban that does.( 39 , 40 ) Some otherwise restricted care may be allowed under 20 bans for undefined “infection, injury, disease, or disorder…caused by or exacerbated by [GAMC],” and under 16 bans for unspecified physical conditions that place an individual at risk for “death or impairment of major bodily function.” West Virginia’s 2023 ban permits GAMC for so-called “severe” gender dysphoria, situating it as the only state that does not have an absolute TGD-specific prohibition. Four bans include an exception for penile circumcision. Additional exceptions are cataloged in Appendix Table 3 . Twenty-four of the 30 bans define sex as a binary biological condition of being female or male, as determined by chromosomes, endogenous steroid hormones, reproductive potential, internal reproductive organs, and/or external genitalia present at birth ( Appendix Table 2 ). Sixteen bans invoke the concept of “nonambiguous” genitalia as a criterion for their definition. Twelve bans define gender as “the psychological, behavioral, social and cultural aspects of being male or female,” without mention of TGD identities. Eleven bans describe GAMC as a form of “gender transition” or a similar term. Referring a TGD minor for – or otherwise “aid[ing] and abet[ting]” – restricted GAMC is prohibited in seven bans. Punitive actions vary across bans and may involve loss of licensure, financial penalties, and criminal and civil charges for healthcare professionals (HCPs). DISCUSSION GAMC bans prohibit hormonal or surgical alterations to the benign sexual anatomy of TGD minors. This applies even to adolescents who may both need and want this care within their states of residence, and who are supported in accessing it on a voluntary basis by their parents and HCPs. However, statutory carve-outs for intersex “normalization” procedures explicitly permit such interventions even when non-voluntary, raising questions about potential double standards. Interventions on intersex individuals are not the only excepted circumstances involving benign sexual anatomy within the bans. In the United States, uniquely among high-income countries, non-therapeutic, non-religious (so-called “routine”) infant penile circumcision remains a majority birth custom. Like intersex “normalization” procedures, such circumcision is performed in healthcare settings without the consent or assent of the individual and in the absence of a physical health condition that requires urgent medical intervention.( 41 ) Several bans explicitly legitimize such circumcisions on healthy endosex male infants, such as New Hampshire’s statute permitting HCPs to remove benign penile foreskin for “religious, cultural or health reasons.”( 42 ) Beyond circumcision, labiaplasty( 43 ) and other cosmetic surgeries that alter or remove non-diseased sexual or genital tissues are increasingly performed on non-TGD minors( 44 – 47 ) and seem set to continue in states with GAMC bans, although they are neither explicitly restricted nor excepted. Carve-Outs Undermine Arguments for GAMC Restrictions Proponents of the GAMC bans who also support the carve-outs for intersex interventions might argue that, unlike children without VSCs (inclusive of TGD minors), children born with VSCs have a recognized physical health condition and are therefore appropriate subjects of surgical or hormonal medical treatment, even without their personal consent or assent. However, as noted, most VSCs do not pose a significant or time-sensitive threat to physical health, which undermines the force of this position. Such a justification also fails to explain the carve-outs for non-therapeutic infant penile circumcision.( 49 ) Like intersex “normalization” procedures, “routine” circumcision in the U.S. serves to conform a child’s body to what is considered typical – or culturally acceptable – for members of one’s designated sex class and presumed gender identity, irrespective of consent or medical necessity.( 50 ) This suggests that the carve-outs, taken together, may have more to do with upholding traditional gender norms about bodily appearance than with addressing a relevant physical health concern.( 50 ) Proponents of GAMC bans argue that there is scientific uncertainty about the effectiveness of GAMC interventions in bringing about positive outcomes. The most oft-cited review in this area( 51 ) characterizes the existing evidence base as being generally of a low quality. This review has itself also been subject to critique.( 52 – 54 ) However, such discourse by ban proponents – about the ostensibly low quality of research for GAMC – ignores the fact that the evidence base regarding long-term causal benefits of non-voluntary intersex procedures (compared to no, or voluntary procedures) is of no greater, or arguably even lower, quality.( 19 ) Of course, better-quality research is desirable in all areas of healthcare, particularly when dealing with vulnerable populations. The point here is simply one of consistency: if the quality of evidence supporting one set of interventions is deemed, by some, to be too low to permit even case-by-case decision-making by HCPs, parents, and older minors who may seek such interventions, then similar or even lower-quality evidence supporting analogous, but non-voluntary interventions in younger minors should inspire, if anything, even greater concern. And yet, the opposite pattern of concern is what is suggested by the bans, in terms of what is permitted versus restricted. Intersex procedures are typically performed at an early age, when the child’s future (i.e., adolescent or adult) gender identity – and any associated bodily preferences or health needs they may have at that point – are a matter of speculation. By contrast, for TGD individuals who actively request GAMC in adolescence or adulthood, such information is already available and can be factored into a shared decision-making process around potential medical interventions, with the meaningful participation of the individual concerned. This allows for judgments to be made on a case-by-case basis with due consideration for the young person’s known (rather than merely anticipated, future) health or identity-related needs and circumstances.( 55 , 56 ) Thus, the ubiquitous intersex carve-out within the GAMC bans may signal a desire to reinforce traditional standards of what is considered “normal” in relation to sex or gender, irrespective of voluntariness, rather than to make a principled distinction based on relative risks and benefits or a minor’s capacity to consent. Narrow Sex and Gender Definitions In the GAMC bans, both intersex people and TGD people are excluded from the narrow definitions of sex and gender that are employed, respectively. The bans criminalize HCPs who provide or refer for voluntary GAMC for TGD minors, while codifying practices that allow similar, but non-voluntary treatments on the sexual anatomy of intersex minors. Infertility, sexual dysfunction, and other physical health risks inherent to medical interventions on benign sexual anatomy are, paradoxically, proffered to justify restrictions on care for TGD minors but disregarded within statutory carve-outs for similar procedures on non-TGD minors. At stake is the health, well-being, and equal rights not only of TGD individuals, but also of non-TGD individuals, whether or not they have intersex traits. The right of all individuals to the highest standard of healthcare, which includes respect for self-determination and bodily autonomy, is threatened by contradictory laws that defer to the judgment of parents and HCPs in some instances (i.e., for non-TGD minors) while superseding them in others (i.e., for TGD minors). Such legislation is antithetical to increasing global calls to develop consistent legal and ethical protections that center the preferences and values of young people in decision-making about medical interventions that affect their own genital and sexual anatomy.( 19 , 20 , 57 , 58 ) Whether TGD or non-TGD, intersex or endosex, all individuals have equal right to make informed decisions about their bodies.( 19 , 59 ) Ideally, any treatments for children with intersex traits should be offered within a multidisciplinary care model that prioritizes informed personal consent as an intrinsic part of so-called “patient centered” care. This approach makes psychosocial, psychotherapeutic, and peer supports accessible to the individual and their family, and ensures respect for the individual’s self-determination and bodily autonomy by obtaining age-appropriate consent or assent for any surgery or hormone therapies that may ultimately be pursued.( 60 – 63 ) The same standard should apply to TGD and non-TGD minors. Relevance to the Politico-Legal Landscape in the United States and Beyond Our findings elucidate the differential statutory rules applied to TGD and presumptively non-TGD minors, rules shaped by definitions of sex and gender that conflict with more nuanced scientific considerations of these concepts. Such legislation discriminately limits healthcare access and delivery for some, while endorsing medically unnecessary, non-voluntary care for others. Similarities across statutes (e.g., preambles, definitions, carve-outs) may reflect the influence of model legislation developed by medico-legal groups with particular views on sex, gender, and GAMC.( 64 , 65 ) Notably, state governors exercised veto powers for seven bans (though five vetoes were overridden), criticizing governmental overreach and highlighting potential unconstitutionality.( 66 – 72 ) The U.S. Supreme Court is considering whether Tennessee’s ban on GAMC constitutes sex-based discrimination,( 73 ) which is prohibited under the Equal Protection Clause of the U.S. Constitution’s 14th Amendment. Federal actions under the newly inaugurated Trump-Vance administration appear poised to perpetuate a comparable contradiction to that found in our analysis. Importantly, while enacted GAMC bans in the U.S. may seem to permit appearance-“normalizing” alterations on infants and children born with VSCs, these interventions have neither been declared clearly legal or illegal under U.S. law. In contrast, numerous other countries have explicitly prohibited such practices.( 74 ) The United Nations, World Health Organization, and U.S. Department of Health and Human Services under the Biden-Harris administration have also expressly endorsed the fundamental rights of people with intersex traits – like people of all sexes and genders – to bodily integrity and bodily autonomy.( 7 , 75 – 77 ) The Trump-Vance administration, however, is charting a federal policy agenda that, like the state legislation identified in our analysis, focuses on sex, gender, and GAMC. During the first two weeks of the current administration, an executive order (EO) established, for all federal policy and administrative purposes, a binary definition of sex based on the capacity to produce gametes at conception.( 78 ) This theoretical definition is inconsistent with real-world methods of human sex classification, especially in the case of persons born with VSCs.( 79 ) Gamete production is not assessed at conception or birth, and decisions made on the basis of actual or hypothetical gamete-making capacity may conflict with more comprehensive methods of classifying an individual’s sex based on a wider set of relevant features.( 80 , 81 ) Another EO defined GAMC as “chemical and surgical mutilation” of TGD individuals under the age of 19 years and called to prohibit federal activities that “fund, sponsor, promote, assist or support the so-called ‘transition’ of a child from one sex to another.”( 82 ) Poised to variably impact GAMC for not only TGD minors, but also some TGD legal adults within healthcare systems across the United States, this executive communication has spawned litigation attempting to block its implementation.( 83 – 87 ) The EO also called for enforcement of the U.S. federal Female Genital Mutilation/Cutting (FGM/C) statute,( 88 ) conflating GAMC with FGM/C despite ethically relevant differences. Notably, the U.S. federal prohibition on FGM/C forbids all medically unnecessary alterations to the external female genitalia of persons under the age of 18 years,( 89 ) but has not been interpreted as protecting individuals born with VSCs from such alterations, even if they were classified as female at birth and if similar anatomical features (e.g., clitoral tissues) would be affected.( 90 – 92 ) International FGM/C legislation also contains explicit or de facto intersex exceptions.( 93 , 94 ) While the enforceability and implementation of the EOs are uncertain, these federal moves implicate both TGD and intersex persons. Alongside state and federally( 95 , 96 ) legislated restrictions on GAMC, the Trump-Vance administration has also orchestrated removal of peer-reviewed and other scientific information on TGD and intersex populations.( 97 ) Limitations This analysis excludes statutes passed or enacted during the 2025 legislative session, which is still in process as of publication. In February 2025, Kansas’ legislature overrode a gubernatorial veto to become the 27 th U.S. state to enact a GAMC ban.( 98 , 99 ) In April 2025, the West Virginia legislature amended its 2023 ban,( 100 ) notable for allowing GAMC for so-called “severe” gender dysphoria, to completely remove this exception (the revised law is awaiting the governor’s signature at the time of writing); in any case, this carveout is likely inoperable because gender dysphoria is not graded by severity in clinical practice ( 48 ). These 2025 bans contain equivalent definitions of sex and gender to those documented here ( Appendix Table 2 ), alongside similar restrictions on hormonal and surgical interventions for TGD minors; exceptions for interventions on individuals with VSCs; and penalties for statutory violations. CONCLUSION Legislative bans on GAMC across U.S. states restrict medical services that affect benign sexual anatomy, and do so in a discriminatory manner. Access to and delivery of healthcare services are limited for TGD individuals who desire them, while implicit permissions are codified for medically unnecessary, appearance-”normalizing” interventions on infants and children with VSCs, thus preempting their ability to personally consider, much less assent or consent to, such procedures. We conclude that neither TGD restrictions nor intersex exceptions within these bans protect minors’ right to self-determination and their growing capacities for bodily autonomy. They instead reinforce the pathologization of gender and anatomical diversity in the name of social norms and conformity. Sound health policy uses science and ethics to afford equal access to healthcare services without discrimination based on sex, gender, or other protected characteristics. Lawmakers and politicians across all jurisdictions in the United States must protect the moral and legal right of all individuals to seek or forgo care that modifies their sexual anatomy in a way that acknowledges and respects their bodily sovereignty. Data Availability All data are available in the included appendix. APPENDIX View this table: View inline View popup Download powerpoint Appendix Table 1. Definitions for terminology used in this paper, conforming to broadly accepted standards within scientific and medical communities*. View this table: View inline View popup Appendix Table 2. Elements of U.S. laws restricting medical care for transgender minors, 2021-2024 (N=30). View this table: View inline View popup Appendix Table 3. Exceptions in U.S. laws restricting medical care for transgender minors, 2021-2024 (N=30). Appendix Box 1. Detailed methodology. We searched for statutes across four full legislative sessions (January 1, 2021, to December 31, 2024) that restrict healthcare services for TGD individuals in all 50 U.S. states, the District of Columbia, U.S. territories, and tribal and federal jurisdictions. Using publicly available legislative trackers,(30-33) one statute of interest was reviewed for each legislative session (AR in 2021, AL in 2022, GA in 2023, OH in 2024) to identify key terms. Lexis Nexis was then queried for all jurisdictions of interest (excepting American Samoa, for which data were not available) with bill text of enrolled and enacted statutes containing the terms: “gender transition,” “gender dysphoria,” “gender reassignment,” “sex reassignment,” “gender-related condition,” “nonambiguous genitalia,” or “irresolvably ambiguous.” Identified statutes meeting our inclusion criteria (Appendix Exhibit A2), including those that were vetoed or under injunction, were cross-validated with the jurisdiction’s government website. They were then assessed through sequential, independent review by two authors (SAM, HCW). For each statute, the authors identified descriptions of sex, gender, and GAMC; restricted healthcare services; stated purpose(s) for which services are restricted; exceptions to restrictions; and penalties for statutory violations. All quoted text denotes statutory language. Download figure Open in new tab Appendix Figure 1. Flow diagram for identification of statutes, inclusion and exclusion criteria. View this table: View inline View popup Appendix Table 4. U.S. laws restricting medical care for transgender minors, 2021-2024 (N=30). Footnotes Note: This is a preprint of a manuscript that has not yet undergone peer review. It may be cited as: Mar, S. A., Indig, G., McNamara, M., Boskey, E. R., Dalke, K. B., Dietz, E., Carpenter, M., Kraus, C., Lorshbough, E., McLamore, Q., Zieselman, K., Earp, B. D. & Wenger, H. C. (2025). Intersex exceptions in U.S. laws restricting medical care for transgender minors. medRxiv . ENDNOTES/REFERENCES 1. ↵ Committee on Measuring Sex, Gender Identity, and Sexual Orientation, Committee on National Statistics, Division of Behavioral and Social Sciences and Education, National Academies of Sciences, Engineering, and Medicine. Measuring Sex, Gender Identity, and Sexual Orientation [Internet] . Bates N , Chin M , Becker T , editors. 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Available from: https://www.science.org/content/article/health-agencies-purge-trump-targeted-programs-and-websites 98. ↵ The Help Not Harm Act, Kan. S.B. No. 63 § 1, 3-5 ( 2025 ). https://sos.ks.gov/publications/register/Volume-44/Issues/Issue-08/02-20-25-52891.html . 99. ↵ Kelly , L. Veto Message, Kan. S.B. No. 63 ( 2025 ). https://www.kssos.org/publications/sessionlaws/2025/Message-01-SB-63.html . 100. ↵ Walker , J. Legislators pass bill to fully ban gender-affirming care, scrapping exemption for suicidal teens . WV Public Broadcasting . Available from https://wvpublic.org/legislators-pass-bill-to-fully-ban-gender-affirming-care-scrapping-exemption-for-suicidal-teens/ View the discussion thread. Back to top Previous Next Posted April 22, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. 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