(CNN) LGBTQ advocates are warning that the influx of anti-transgender legislation being proposed in many states will harm trans and nonbinary youth.
Twenty-eight states are considering anti-trans bills, according to the American Civil Liberties Union (ACLU). The bills put forth this year predominantly fall into two categories: removing trans girls' ability to participate in girls' sports, and restricting young trans peoples' access to gender-affirming health care.
While many of them may not become law, bills in three states -- Tennessee, Mississippi and Arkansas -- have already been passed and signed by state governors this month.
"This has been a significant part of my work at the ACLU for the past six years and I've never seen anything like this," said Chase Strangio, deputy director for transgender justice at the ACLU. "There have never been this many bills targeting trans youth voted out of committee and then making it to the floor."
Over 60 anti-trans bills are being considered across the country, according to the ACLU. LGBTQ advocates, including Strangio, are concerned that the proposed laws will harm trans athletes, and make it easier to limit trans people's access to health care.
"There have been many existential threats to trans existence, but there's something uniquely dangerous about what's going on right at this moment with the combination of the sports bills and the health care bills," Strangio told CNN. "I think the impulse underlying both is to try to establish governmental policy that it's harmful to be trans."
Much of the legislation that is pending or has been adopted restricts athletes' participation in public school sports to the gender that matches the sex that athletes were assigned at birth. But it's not possible to know a person's gender identity at birth, and for some people, the sex listed on their original birth certificate is a misleading way of describing the body they have.
While sex is a category that refers broadly to physiology, a person's gender is an innate sense of identity. The factors that go into determining the sex listed on a person's birth certificate may include anatomy, genetics and hormones, and there is broad natural variation in each of these categories. For this reason, the language of "biological sex," as used in this legislation, can be overly simplistic and misleading.
Last year, Idaho passed a bill banning trans girls' participation in sports -- but the law was blocked by a federal judge over the summer.
"The State has not identified a legitimate interest served by the Act that the preexisting rules in Idaho did not already address, other than an invalid interest of excluding transgender women and girls from women's sports entirely, regardless of their physiological characteristics," Judge David Nye wrote in August of 2020.
This year, however, other states have introduced similar legislation more successfully.
Transgender girls and women in Mississippi's public schools and colleges will no longer be allowed to compete in women's sports after the state's Republican governor on March 11 signed the first statewide anti-trans law of 2021.
"This important piece of legislation will ensure that young girls in Mississippi have a fair, level playing field in public schools," Mississippi Gov. Tate Reeves said during the signing event, even though Mississippi's trans girls would see some of their rights taken away by the new law.
More recently, Tennessee Gov. Bill Lee signed an anti-trans sports bill into law requiring students to prove their assigned sex at birth, and compete as part of teams of the corresponding gender, in order to play in middle and high school sports.
The bill states that "a student's gender for purposes of participation in a public middle school or high school interscholastic athletic activity or event be determined by the student's sex at the time of the student's birth, as indicated on the student's original birth certificate."
Students must show proof of the sex they were assigned at birth if their birth certificate does not appear to be the original or does not indicate the student's assigned sex at the time of birth. This does not apply to students in kindergarten through fourth grade, the Tennessee bill says.
Also last week, Arkansas Gov. Asa Hutchinson signed the "Fairness in Women's Sports Act," which bans trans girls and women from participating in school sports consistent with their gender identity.
According to the law, Arkansas aims to divide school sports according to the sex listed on students' birth certificates rather than gender identity.
It applies to all sports sponsored by public schools beginning from the elementary level and up through college. Private schools will be held to the same standard if they compete against a public school.
"This law simply says that female athletes should not have to compete in a sport against a student of the male sex when the sport is designed for women's competition," Hutchinson, denying that trans women are women, said in a statement after signing the measure into law.
Though only legislation around sports bans have been codified into law so far this year, trans advocates warn that legislation targeting access to health care is approaching passage in some states.
On Monday, the Arkansas Senate voted 28-7 to approve will the Arkansas Save Adolescents from Experimentation (SAFE) Act, a measure that would prevent gender transition "procedures" for trans people under age 18.
The bill makes what it calls an "exception" for some intersex people with unspecified chromosomal makeup and hormone production, and those with difficulties resulting from previous gender-affirming treatments.
For young people experiencing gender dysphoria -- a diagnosis that includes the significant distress that can result from identifying as a gender different than one's sex assigned at birth -- this would mean not being able to access puberty-blockers, a treatment option for transgender youth that is used to prevent the onset of puberty.
The treatment sometimes gives young people temporary relief from the symptoms of gender dysphoria, according to the American Academy of Pediatrics.
The Arkansas SAFE Act would also ban so-called "cross-hormone therapy," a gender-affirming treatment that allows for trans people to change their physical appearance to be more consistent with their gender identity.
Arkansas State Rep. Robin Lundstrum, who proposed the Arkansas SAFE ACT, has made comments that contradict the science of gender identity, and falsely positioning trans and nonbinary identities as a "choice."
"Those kids are precious. Some of them may choose to be transgender when they're older. That's okay, that's their choice," Lundstrum said during a House panel prior to passing the bill, as an explanation for why he supports denying them life-saving medical care. "But when they're under 18, they need to grow up first. That's a big decision, there's no going back."
A dozen states have bills similar to the Arkansas SAFE Act, according to the ACLU's anti-trans bill tracker.
Some conservative, anti-trans groups, like the Family Policy Alliance and Heritage Foundation, said they back measures like the Arkansas SAFE Act and other similar proposals.
"The psychological aspect of the treatment of gender dysphoria needs to be thoroughly investigated and debated," Emilie Kao, director of the Richard and Helen DeVos Center for Religion & Civil Society at the Heritage Foundation, told CNN, despite extensive published research from medical experts on this topic.
"Because the most authoritative studies of those people with gender dysphoria who have gone through surgical intervention show that there is an increase in the level of suicidal ideation after going through surgeries," said Kao, citing a 2011 Swedish study that is frequently cited by those who seek to undermine trans rights and gender affirming health care.
The study's lead author, Cecilia Dhejne, has since said in an interview with The Trans Advocate that her study's findings have been widely misinterpreted, and "studies thereafter show that medical gender confirming interventions reduces gender dysphoria."
But other groups, like the American Psychiatric Association and The American Academy of Pediatrics, have come out against the health care bans.
The proposed bills contradict medical guidelines from several associations, including the Endocrine Society, which recommends that trans youth work with mental health professionals and doctors to seek appropriate treatment, including puberty blockers.
Trans advocates and experts argue that these bills do anything but protect young trans people.
"Affirming health care can literally be life or death for anyone, but particularly for trans youth," Raquel Willis, a Black trans activist and writer, told CNN. "People think that's an exaggeration. It's not. People think you can just discipline identity out of someone and that is not true and in many ways is torture."
Transgender youth have a much greater risk of suicide, according to the US Centers for Disease Control and Prevention. However, if they have access to a puberty blocker, their chances of suicide and mental health problems in the immediate term and down the road decline significantly, a study published in January of 2020 found.
"All existing studies show that regret following gender-affirming medical care is rare," Dr. Jack Turban, a fellow in child and adolescent psychiatry at Stanford University School of Medicine, who researches the mental health of transgender youth explained, "existing medical guidelines recommend against gender-affirming genital surgeries for minors."
He said the psychological effects of gender dysphoria can be harmful to young trans peoples' bodies.
"We have seen patients with rib fractures from being so dysphoric towards their developing chests that they tightly bind their chests with tape or ace bandages, adolescents who required surgery because their intestines were damaged from not going to the bathroom due to genital dysphoria, and countless patients who had mental health crises related to pubertal progression," Turban said.
"Our recent study in the journal Pediatrics found that those who access pubertal suppression during adolescence have lower odds of considering suicide than those who aren't able to access this intervention. In contrast, our research shows that attempts to force transgender people to be cisgender result in greater odds of suicide attempts."
Clarification: This story has been updated to provide additional explanation as to the distinctions between gender and sex.
Correction: An earlier version of this story did not fully describe the Endocrine Society's views on the use of puberty blockers. The society recommends that trans youth work with mental health professionals and doctors to seek appropriate treatment, including puberty blockers. The story also gave the wrong date for a Centers for Disease Control and Prevention study on the risks of suicide among transgender youth. It was January 2020.