Democratic governors and state lawmakers across the country are mobilizing against a surge of Republican restrictions on transgender health care by establishing their states as sanctuaries for gender-affirming care.

Earlier this month, Democratic Gov. Wes Moore signed an executive order making Maryland the 11th state, plus the District of Columbia, to declare itself a sanctuary. A bill in New York has cleared the legislature and is awaiting the signature of Democratic Gov. Kathy Hochul.

Last year, California became the first state to declare itself a sanctuary. It has since been joined by Colorado, Connecticut, Illinois, Maryland, Massachusetts, Minnesota, New Jersey, New Mexico, Vermont and Washington. A growing number of cities, including New York City; Kansas City, Missouri; and West Hollywood, California, also have become sanctuaries.

These states and cities are emerging as havens with legal protections to shield health care providers, transgender people and their supporters from lawsuits and criminal penalties levied by other states.

Maryland’s executive order prohibits the use of state resources, such as incarceration facilities, to comply with subpoenas against transgender people and their health care providers. It mandates that all state agencies “take whatever action is necessary” to protect those involved in providing, receiving or assisting in travel for gender-affirming care.

The order also ensures that transgender people will not be extradited from Maryland for seeking gender-affirming care, and doctors will not lose their licenses for providing such care. Similar measures have been implemented by other sanctuary states.

New York Democratic Assemblymember Harry Bronson, who led the effort to pass the sanctuary bill in the lower house, highlighted his state’s commitment to embracing and protecting transgender people.

“That’s what New York state is saying by this piece of legislation, that we love you for who you are, and we’re going to support you for who you are,” Bronson said in an interview with Stateline. “We’re going to make sure that whatever legal means we have, we’re going to make sure that you’re protected from those who will hate.”

Republican-led efforts to curtail or criminalize providing or receiving gender-affirming medical treatment have gained momentum in recent years, fueled by concerns over parental rights, religious beliefs and the ongoing debate surrounding gender identity.

At least 20 states have restricted or banned gender-affirming care for minors, according to data from the Movement Advancement Project, a nonprofit think tank that advocates for LGBTQ+ rights.

At least five states — Alabama, Florida, Idaho, North Dakota and Oklahoma — have made it a felony to provide gender-affirming care to minors. In other states, laws range from banning the use of public funds or state property to provide care or promote social transitioning, to prohibiting out-of-state providers from delivering telehealth care.

On Tuesday, a federal judge struck down Arkansas’ ban on gender-affirming medical care for transgender minors. The ban, which had been blocked from going into effect for nearly two years, prohibited physicians from providing “gender transition” treatments such as hormones, puberty blockers and surgeries to those under age 18.

Idaho’s Vulnerable Child Protection Act, which was signed into law in April by Republican Gov. Brad Little, bans puberty blockers, hormones and surgeries for minors. The law also makes providing gender-affirming health care for minors a felony with a penalty of up to 10 years in prison.

“In signing this bill, I recognize our society plays a role in protecting minors from surgeries or treatments that can irreversibly damage their healthy bodies,” Little wrote in a transmittal letter to state lawmakers. “However, as policymakers we should take great caution whenever we consider allowing the government to interfere with loving parents and their decisions about what is best for their children.”

Some states, including Arizona, Georgia and Texas, approved bans with exceptions, such as allowing medication or nonsurgical gender-affirming care and allowing minors who were diagnosed or receiving treatment prior to the law’s passage to continue or wean off medication.

Many of the laws explicitly bar gender-affirming treatments such as hormone therapy and surgeries for transgender minors. Proponents argue that they protect children from making potentially irreversible medical decisions, while preserving parental authority.

“There is no doubt that these procedures are ‘abuse’ under Texas law, and thus must be halted,” Texas Attorney General Ken Paxton said in a February statement. “The Texas Department of Family and Protective Services (DFPS) has a responsibility to act accordingly. I’ll do everything I can to protect against those who take advantage of and harm young Texans.” (Paxton has since been suspended from office and faces an impeachment trial.)

Olivia Hunt, the policy director for the advocacy group National Center for Transgender Equality, said proponents of transgender health care bans often misrepresent transition-related health care as new or experimental to garner support.

“The science reliably shows that the proponents of anti-trans policies are simply wrong,” Hunt said in an interview with Stateline.

Gender-affirming care encompasses both medical and non-medical services, such as social affirmation, puberty blockers, hormone therapy and surgical procedures, according to the U.S. Department of Health and Human Services.

Social affirmation involves adopting or using a name, hairstyles, clothing, pronouns and restrooms or other facilities that correspond to one’s gender identity, according to the department.

Surgeries are typically reserved for adults, although they may be considered for adolescents on a case-by-case basis, the department said.

Leading medical associations, including the American Academy of Pediatrics, endorse gender-affirming care as safe and effective. The American Medical Association considers it medically necessary, highlighting the importance of these interventions in supporting the well-being of transgender individuals.

However, some European nations, including Norway, Finland, Sweden and the United Kingdom, recently have introduced restrictions on gender-affirming care for minors.

Research conducted by public health authorities in England, Finland and Sweden has not shown “meaningful improvements in youth’s mental health” as a result of gender-affirming care, according to an article published in the journal Current Sexual Health Reports in April. The article also suggested that puberty blockers may hinder bone development.

Attitudes toward transgender people and issues in the United States are divided, according to polling data from the Pew Research Center. Although the survey found that 64% of adults support transgender nondiscrimination laws, 60% also hold the belief that a person’s gender is determined by the sex assigned at birth, and 46% support legislation that would prohibit gender-affirming health care for minors.

At least 130 bills restricting gender-affirming health care have been introduced in state legislatures across the country this session — a roughly threefold increase from 43 bills last year, according to American Civil Liberties Union data.

The consequences of transgender health care bans are profound, Hunt said. These restrictions may exacerbate gender dysphoria — a disconnect between a person’s gender identity and their assigned sex at birth — leading to heightened rates of depression, anxiety and self-harm, according to research cited by the Association of American Medical Colleges Center for Health Justice.

“Having your civil rights up as a matter of public debate is one of the most stressful things that you can do to anybody who’s part of a marginalized population,” Hunt added.

In addition to simply declaring themselves sanctuaries, Hunt said, states that want to support the health care needs of transgender people should pay attention to insurance coverage and affordability.

“When politicians are considering these sanctuary refuge laws, they also need to look at what they’re doing to ensure broader equity for people who are trying to rely on them to actually access care, access social services and be able to lead fulfilled lives as part of the communities they’re moving into,” she said.

Transgender health care bans have led a growing number of transgender people to seek refuge elsewhere.

“Trans people who can afford to do so and have the flexibility to do so are often picking up and leaving,” Hunt said. “That’s creating people who are refugees within our own country. That’s something that every lawmaker that’s voting in favor of these bills — those that are attacking their own constituents — should be deeply ashamed of.”

Recent polling data gathered by Data for Progress, a progressive think tank and polling firm, showed that at least 43% of transgender adults have considered relocating and another 8% have already relocated due to anti-LGBTQ+ legislation.

Sheresse Jackson, a transgender woman who relocated from Philadelphia to Baltimore about a year ago, said she discovered a newfound sense of belonging and purpose in her new home.

“I love Baltimore. I love being trans. I wouldn’t change it for nothing in the world,” she said in an interview with Stateline. “I can say it’s making me a better person to be Sheresse because back home, I had my mind on the streets still — running around doing nothing with my life other than working. But being Sheresse, now I’m in school to try to get my CNA [certified nursing assistant] license and my high school diploma.”

Maryland’s sanctuary status, Jackson said, fosters an environment in which transgender people can experience a sense of safety, acceptance and comfort.

“To make [Maryland] a sanctuary state, that will be good for other trans people that’s in the closet and for the ones that’s out because you’ll have a place where you can come to feel safe and comfortable,” Jackson said.

Prior to becoming a sanctuary state, Maryland enacted the Trans Health Equity Act, which eliminated state-imposed restrictions on who can receive gender-affirming care, leaving the decision-making process to patients and their doctors. Moreover, the law overturned the previous prohibition on gender-affirming care for Medicaid recipients under 18.

Maryland state Del. Kris Fair, one of the bill’s sponsors and the chair of the LGBTQ+ Caucus, emphasized the importance of providing equitable health care options for the transgender community.

“Ensuring that trans people have access to the same medical health care options that every other American has is a critical piece towards ensuring that there is a sense of equity in our society,” Fair said.

This article was initially published by Stateline, an affiliate of States Newsroom.