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A new law in California protects transgender youth who come for medical care

Lesley McClurg

California is now a sanctuary for transgender youth who come for medical care. A new law protects families traveling from places where there are efforts to criminalize gender-affirming care.

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California Becomes First Sanctuary State for Transgender Youth Seeking Medical Care

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a young man and his mom smile for a portrait wearing purple shirts that read 'I support LGBTQ youth'

California is the first state in the nation to create a sanctuary for transgender youth seeking gender-affirming medical care. Gov. Gavin Newsom signed a new law in September that ensures transgender kids from elsewhere can safely access hormones or puberty blockers here. The legislation also shields families from child abuse investigations or from being criminally prosecuted for seeking gender-affirming care.

“In California we believe in equality and acceptance. We believe that no one should be prosecuted or persecuted for getting the care they need — including gender-affirming care,” Newsom said in a signing message . “Parents know what’s best for their kids, and they should be able to make decisions around the health of their children without fear. We must take a stand for parental choice.”

This year a wave of bills in states ranging from New Hampshire to Arizona have attempted to limit, ban or criminalize access to medical care for transgender and nonbinary youth. An Alabama law passed in February not only banned medication for transgender youth, but ruled that doctors who break it could face up to 10 years in prison.

“You don’t disfigure 10-, 12-, 13-year-old kids based on gender dysphoria,” Florida Gov. Ron DeSantis said at an August press conference . “I think these doctors need to get sued for what’s happening.”

Most of these laws are in legal limbo as they are challenged in court . Meanwhile, families are panicking.

Scared out of Texas

After decades of building a life in Texas, a mother of a 12-year-old suddenly worried she might be investigated for child abuse, after Gov. Greg Abbott ordered the Texas Department of Family Protective Services to investigate parents who are providing gender-affirming care to their kids last February.

“We were stunned that it was no longer safe for us to be there,” said the mother, who asked that KQED not use her name to protect her identity and that of her child.

Even after a Texas judge temporarily stayed such investigations , Texas Attorney General Ken Paxton insisted that they were legal and would continue .

Media reports soon detailed experiences where state investigators pulled trans youth out of classrooms for interrogations.

“With their parents not being there,” said the Texas mother, adding that she heard similar stories from family friends. “And these are children that have only socially transitioned. All they asked for was to be called a different pronoun. That’s terrifying.”

Three years ago, her own 12-year-old daughter asked her friends and family to use feminine pronouns.

“And so we sat down and talked to our kid,” she said. “We gave her a little card to go to school with that listed her rights and told her what to do if somebody came to investigate us.”

But the family could not relax. They said they had no choice but to sell their home. This fall they packed up all of their belongings and moved to Southern California.

“It feels very good to not feel like you’re in danger — in that really critical place of our family being ripped apart,” said the mother.

Providing refuge

They feel safe under a new law authored by state Senator Scott Wiener (D-San Francisco), which declares that any potential out-of-state arrest warrant for violating laws related to such care will be given “the lowest law enforcement priority.”

“We are going to provide them with refuge and we’re not going to send them back and we’re not going to honor subpoenas,” said Sen. Wiener. “And our law enforcement is not going to enforce the laws of Texas and Alabama criminalizing these families.”

High stakes

Mental health therapists say puberty blockers and hormone therapy can save lives . A recent survey found that nearly 1 in 5 transgender 13- to 24-year-olds have attempted suicide in the past year.

The World Health Organization defines gender-affirming care as a variety of “social, psychological, behavioral and medical interventions designed to support and affirm an individual’s gender identity.”

These interventions can be nonmedical — called social transitioning — like when a child adopts a chosen name and/or new pronouns or dresses in alignment with their gender identity. Research suggests changing one’s name may reduce depression and suicide ideation.

Also, beginning in early adolescence, doctors may prescribe medical interventions. The World Professional Association for Transgender Health recommends waiting until youth are 15 years old for surgical procedures, according to their new guidance released over the summer.

Constitutional questions

The new California law faces fierce opposition. Forty-five organizations, including the Alliance Defending Freedom and The Heritage Foundation , penned a letter to Newsom urging him to veto Wiener’s bill.

“We want these treatments to not be happening on minors because they’re permanent,” said Greg Burt, director of capitol engagement for the California Family Council , a Christian faith-based organization. “We do not assume that your body is the problem. We think it’s much more logical to encourage young people to try and get their minds to match their bodies.”

a person wears a shirt that reads 'protect trans kids'

Yet the standard of care for kids who are really distressed and diagnosed with gender dysphoria does include medical interventions.

California is also acting as a sanctuary for those individuals seeking abortions from other states after the U.S. Supreme Court overturned Roe v. Wade, the historic 1973 ruling that granted a legal right to the procedure. But conservatives, including Burt, argue that California’s “sanctuary” laws on abortion and gender-affirming care violate the Constitution.

“There’s going to be a constitutional crisis if states don’t honor each other’s civil judgments,” Burt said.

Jessica Levinson, professor at Loyola Law School in Los Angeles, said there “could be litigation both with respect to abortion and with respect to gender-affirming care.”

But she and other legal experts are not convinced by conservative critiques that the new California laws violate the Constitution’s full faith and credit clause .

“I think the weight of the law indicates that states are separate sovereigns. If and until there is a national standard that indicates nobody can obtain gender-affirming care or nobody can obtain an abortion, the law allows for a patchwork,” Levinson said.

That patchwork is crucial to the families seeking help at Trans Family Support Services in San Diego.

“The politicians should not be making medical decisions for anybody, nor should they be making parental decisions for anybody,” said Kathie Moehlig, the organization’s executive director.

About a decade ago, Moehlig helped her 11-year-old access puberty blockers.

“My son would not still be alive if we waited until 18,” she said. “He already was in so much distress and so completely miserable that his body was becoming something that he knew he was not.”

Today she says her son is thriving in college, studying theology. He has never regretted transitioning.

There is no solid data on how many kids remain satisfied with medical interventions, or feel remorse about gender-affirming transitions. A recent report from Reuters highlights the lack of solid evidence on the long-term effects of gender-affirming care . For example, there is very little known about how transitioning affects fertility or cognitive development. Puberty blockers and sex hormones do not have FDA approval for children’s gender care, and the National Institutes of Health has said that clinical trials have not yet determined whether there are any short- or long-term health risks for teens.

For the Moehlig family, their only regret is that they waited as long as they did to transition their son.

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California set to become a refuge for transgender health care

A national wave

The bill, perhaps the highest profile of several LGBTQ-related proposals also signed by Newsom, responds to a recent wave of legislation: At least 40 bills in 20 states would restrict access to gender-affirming medical care for transgender youth. These proposals vary from an Idaho bill to criminalize gender-affirming medical procedures to a Florida law banning their insurance coverage . In Texas, state social workers are reportedly rebelling — or even threatening to quit — rather than carry out an order by Gov. Greg Abbott to investigate parents who allow transgender health care.

Proponents of the bill say it is California’s responsibility to intervene.

“There are efforts all across the country…to go after trans kids and their families. California has a role to play in providing a safe, welcoming environment for trans kids and their families to get the care they need,” said Samuel Garrett-Pate, managing director of external affairs for Equality California, which supports the bill and says it’s the nation’s largest LGBTQ civil rights group.

SB 107 would:

Prohibit law enforcement participation and the arrest or extradition of an individual for allowing a person to receive or provide gender-affirming care when that care is legal under California and federal law.
Declare arrest warrants for individuals who allowed their child to receive gender affirming health care the lowest law enforcement priority.
Ban the enforcement of another state’s law authorizing a state agency to remove a child from their parent or guardian because they allowed their child to receive gender-affirming care.
Bar compliance with subpoenas seeking medical information related to gender-affirming care that interferes with a person’s right to allow a child to receive that care.

“As it stands, transgender youth and their parents in these states are under a constant threat of being reported by anyone around them, while foregoing life-saving treatment,” said Assemblymember Lori Wilson, a Suisun City Democrat and parent of a trans person, in presenting the bill on the Assembly floor. “In doing so, they are targeting our most vulnerable population — children — as well as their parents and doctors who support them.”

Learn more about legislators mentioned in this story

Scott Wiener

State Senate, District 11 (San Francisco)

Time in office

2016—present

Member, Board of Supervisors

Email Legislator

Race/Ethnicity

Voter Registration

Sen. Scott Wiener has taken at least $980,000 from the Finance, Insurance & Real Estate sector since he was elected to the legislature. That represents 13% of his total campaign contributions.

Lori Wilson

State Assembly, District 11 (Suisun City)

2022—present

Mayor / Finance Director

Asm. Lori Wilson has taken at least $431,000 from the Labor sector since she was elected to the legislature. That represents 22% of her total campaign contributions.

Foes raise concerns

By leaning into the national debate around transgender issues, the bill has generated intense opposition.

Opponents say that children often misunderstand their gender identity and are likely to regret their decision to get irreversible treatments such as hormone replacement therapy and gender-affirming surgery.

“A lot of kids don’t quite comprehend the implications of taking puberty blockers, cross-sex hormones and even some of the surgeries; don’t comprehend the long-term nature and the damaging effect it would have on their on their bodies when they were minors,” said Greg Burt, a spokesperson for the California Family Council .

Burt cited testimony from Chloe Cole before the Assembly Public Safety Committee on June 28.

“SB 107 is circumventing states’ laws and that have needed safeguards in place so my story’s not repeated. Children cannot consent,” said Cole, a 17-year-old from the Central Valley, who medically transitioned from age 13 to 15 with puberty blockers, male hormones and a mastectomy.

Given this, Burt said the religious nonprofit “would be against any kind of drugs or surgeries to try and match a person’s body to their feelings below the age of 18,” regardless of parental consent.

“We don’t let parents sterilize their kids, even if parents consent to it, and we think this is in the same category,” Burt said. “You can’t harm your child permanently, even if you believe the harm is somehow justified.”

However, Sen. Richard Pan, a Sacramento Democrat who is also a pediatrician, said the medical profession does not recommend surgery for transgender individuals under the age of 18. During the floor debate on Wednesday, he cited research showing that the majority of children who question their gender identity do not change their minds and that the majority of treatments provided to transgender youth are reversible.

Opponents also highlight a clause in the bill that they say could take custody rights away from an out-of-state parent who disagrees with the other on their child’s gender-affirming care.

Erin Friday, a San Francisco attorney and parent of a child who once wanted to transition, said that the clause “pits parents against parents” by allowing an out-of-state parent to refile for full medical custody of their child in California and eclipse the consent of the non-affirming parent.

“It makes it easier for the one parent who wants to harm their child to harm their child, and it’s an enticement for kids to run away. There’s no two ways about it,” she said.

Wiener’s office disputes that this is the bill’s intent .

“The point of the bill is not to remove kids from their parents’ custody — not when parents come here with their kids to prevent states like Texas from removing them from their custody,” he said.

Helping families, one at a time

As the political debate rages on, Moehlig and her staff of 10 continue their work, helping families across America figure out the best doctor and how to get insurance coverage, and providing support groups for people from elementary school to age 30. She says her group has assisted 3,000 families in its lifetime.

Kathie Moehlig at her home in Rancho Bernardo in San Diego on Aug. 26, 2022. Photo by Ariana Drehsler for CalMatters

That work convinces her of the importance of the bill. She said it’s “ludicrous” for politicians to assert that they know better than the parents of transgender children and their doctors about what medical care and treatment is best.

As of now, every law that criminalizes gender-affirming care in other states has been delayed by legal challenges. Moehlig, however, said it’s only a matter of time before one of these bills becomes law.

And she’s already seeing the impact: She said she has multiple clients who have moved to California because of the laws in other states. One of her clients in Texas said his doctor canceled his female-to-male top surgery because they were no longer comfortable treating transgender youth.

“I think that protecting the rights of these parents to make these medical choices and get this treatment for these kids without having to worry about any of the ramifications of prosecutions is super important,” Moehlig said.

Ariel Gans was a political reporting intern focusing on the 2022 election cycle. She recently got her master’s of journalism from Northwestern University, where she specialized in politics, policy, and... More by Ariel Gans

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What makes for a transgender safe haven? California, other blue states are figuring it out

A teenager sitting in a ray of sunlight in an otherwise shady area

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WASHINGTON — California stands for “equality and acceptance.”

In Minnesota, “the march of hate and bigotry stops” at its borders.

And New York intends to serve as a “beacon of hope” and a “safe haven for trans youth and their families.”

As red states have moved to restrict the rights of LGBTQ+ people, some Democratic statehouses have rushed to legislate — and message — in the opposite direction, often with enthusiastic endorsements like the above from their governors.

In response to the 20 states that have banned gender-affirming care such as reversible puberty blockers and hormone therapy for minors, more than a dozen states have enacted what have become known as “safe haven” or “shield” laws. Such laws generally prevent state officials from aiding the enforcement of gender-affirming care bans passed in other states, some of which have criminalized providing gender-affirming care, even in other states.

Trans rights activists have praised the new safe haven laws as a necessary step to counter national trends, while also pushing lawmakers to expand — not just protect — transgender rights. But the new laws, they say, can only do so much if they aren’t well-implemented and -funded, or if they aren’t designed to help the community’s most vulnerable members.

“I think it’s always good that we’re seeking to increase protection,” said Terra Russell-Slavin, chief impact officer at the Los Angeles LGBT Center. But, she added, “sometimes it feels more message-driven.”

Minnesota, which passed its shield law in April, borders three states — Iowa, South Dakota and North Dakota — that have banned gender-affirming care for minors as well as transgender youth participation in sports. North Dakota and Iowa are among nine states that have restricted transgender minors from accessing bathrooms that correspond to their gender identity.

But in neighboring Wisconsin, efforts to restrict transgender rights have been blocked by Democratic Gov. Tony Evers. Evers vetoed a provision in the state budget last month that would have blocked Medicaid coverage of gender reassignment surgery and puberty blockers for transgender youth. He previously vetoed a bill to bar trans girls from participating on sport teams that align with their gender identity, and vowed to block a similar bill introduced last month.

Minnesota state Sen. Erin Maye Quade, who wrote the state’s trans refuge bill, said it was focused on making sure that transgender residents aren’t excluded from the protections that cisgender people have. State Rep. Leigh Finke, Minnesota’s first transgender member of the Legislature, wrote the version of the bill passed in the House.

“We wanted to be really explicit that the trans refuge bill is not just about making sure that people know that they’re welcome here and beloved here, but it’s protecting them, and their parents, and their providers, from being prosecuted and jailed for providing or accessing healthcare,” Quade said.

For transgender youths and their families, the messaging around shield laws has a strong appeal. R., a 16-year-old trans boy who lives in northwestern Wisconsin, said he was sitting in his living room with his mother, T., this spring when she showed him an Instagram post announcing Minnesota’s safe haven law. (T. asked that she and her son be identified only by their first initials out of concern for their safety.)

A woman and teenage boy sitting on a concrete dock next to a large body of water spanned by a bridge

“When I found out, it made me feel very safe and accepted, since I live so close,” R. said. “I was like, ‘Oh, that’s nice.’ ... I took a minute to process it, and then I was like, ‘Oh wait, that’s really nice.’”

While gender-affirming care for minors is legal in Wisconsin, R. has been receiving treatment at a clinic in Minnesota. Even if there were a closer clinic, T. said she wouldn’t feel comfortable having her son treated in Wisconsin because the political and legal climate could deteriorate.

She pointed to recent events in Tennessee, where Vanderbilt University Medical Center turned over the files of transgender patients to the state after the attorney general launched an investigation into the hospital for alleged medical billing fraud, the Tennessean newspaper reported in June. Tennessee GOP Gov. Bill Lee signed the state’s ban on gender-affirming care for minors in March.

“I don’t want to put my young person in a place where they’re at risk of that potentially being an outcome for them as well,” T. said. “That’s why I feel a lot safer and more comfortable bringing them to Minnesota for care, especially now, given the sanctuary status that [state has] created.”

More than 86% of transgender and nonbinary people ages 13 through 24 said their mental health had been harmed by debates in state legislatures over laws to limit their rights, and 45% said they had experienced cyberbullying, according to a fall 2022 survey conducted by Morning Consult for the Trevor Project, which runs a 24/7 crisis hotline for young LGBTQ+ people.

California’s shield law, introduced last year by state Sen. Scott Wiener (D-San Francisco), prevents law enforcement from cooperating with other states seeking to enforce gender-affirming care bans on treatment received in California. It also prevents California officials from complying with related out-of-state subpoenas.

“Our priority has been to make clear that as other states demonize and criminalize trans people and try to erase them, to make clear that in California we’re going the opposite direction and we’re embracing our trans people,” Wiener told The Times.

State Sen. Nancy Skinner (D-Berkeley) introduced a bill this session to strengthen the safe-haven law. If passed, it would increase legal protections for healthcare workers providing abortions, contraceptives and gender-affirming care to out-of-state residents.

FILE - In this Oct. 8, 2019, file photo, protesters gather outside the Supreme Court in Washington where the Supreme Court is hearing arguments in the first case of LGBT rights since the retirement of Supreme Court Justice Anthony Kennedy. As vice president in 2012, Joe Biden endeared himself to many LGBTQ Americans by endorsing same-sex marriage even before his boss, President Barack Obama. Now, as president-elect, Biden is making sweeping promises to LGBTQ activists, proposing to carry out virtually every major proposal on their wish lists. (AP Photo/Susan Walsh, File)

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The challenge facing lawmakers and advocates in many blue states is to strike a balance between maintaining existing rights and continuing legislative efforts to improve the physical, emotional and economic well-being of transgender and gender-nonconforming people. That’s an even greater challenge for a state such as California, where progressive social policies come hand in hand with high rents and economic inequality.

“On the policy level, California is definitely one of the better states for legal protection,” said Logan Casey, a senior researcher at the Movement Advancement Project, an LGBTQ+ think tank that tracks national policies. “But one of the things that we know ... is that there’s often a big gap between legal equality, or the actual policies on the books, and lived equality, or what people’s day-to-day experiences look like.”

In 2020, California legislators passed a bill establishing the Transgender, Gender Nonconforming and Intersex (or TGI) Wellness and Equity Fund, aimed at providing grant money to organizations that serve TGI clients to help them improve healthcare access for their communities. The legislation defines healthcare broadly to include mental healthcare, therapeutic care, substance-abuse treatment and access to housing.

In 2021, the state allocated $13 million to the program, including $10.3 million for grants. The California Department of Public Health opened applications for the first round of grants — $2.5 million for gender-affirming care clinics — in June.

“It’s brand-new,” Russell-Slavin said. “Realistically, it takes a while for the funds you get allocated at the state to actually reach the community.”

The effort to enact the TGI Wellness and Equity Fund was advanced by a coalition of groups led by the TransLatin@ Coalition, an organization that advocates for transgender, gender-nonconforming and intersex Latino immigrants. Alexandra Magallon, the TransLatin@ Coalition’s manager of programs and services, said the push for the fund grew out of the difficulties some transgender people — particularly those who are low-income, survive on sex work or don’t have access to computers or the internet — faced in trying to get COVID-19 pandemic benefits.

The goal, she said, was to make sure that “when things like this happen again, that we are structurally able to make sure that our community doesn’t continue to die.”

In Washington state, Democratic lawmakers have passed bills to shield patients who seek abortions or gender-affirming care from subpoenas and warrants issued out of other states; to increase access to district courts for name changes; and to prevent health insurance plans from denying coverage for gender-affirming care.

But when legislatures move quickly in response to national trends, it’s harder to get input from key stakeholders about their priorities, said Jaelynn Scott, executive director of the Lavender Rights Project, a Seattle-based organization that advocates for Black trans people.

Scott praised lawmakers in her state for passing some of the most progressive laws in the country, but said the Legislature had been more “reactive” than “strategic.”

“The reason why we have this perspective at our organization — which is a Black, trans-led organization — is that [for] Black trans people, this is not a new emergency for us,” Scott said. “These bills aren’t really opening up access to the most vulnerable of our communities who need the care the most.”

The state’s shield law, for example, protects people who have traveled to seek care in Washington from states that have criminalized gender-affirming care or abortion. What the bill doesn’t address is how to pay for it.

“What does that do for someone who doesn’t have stable housing, who certainly can’t afford a plane [ticket] to come to Washington state for healthcare, and who never had access to gender-affirming care in the first place?” Scott said. “It’s not written for our communities.”

Beyond shield laws, advocacy groups continue to push for legislation that would make it easier for transgender and gender nonconforming people to change their names and gender markers on government forms; to improve access to and the quality of healthcare that LGBTQ+ people receive through data collection and training for healthcare workers; and for policies that address economic disparities.

A man speaks as people raise pink-and-blue signs behind him, one with the words "Don't mess with trans kids" inside a heart

In Maine, Democratic Gov. Janet Mills signed a bill this year that will allow 16- and 17-year-olds to access gender hormone therapy despite parental objections if they’ve received counseling and can show they would be harmed by not being treated. Mills also signed legislation aimed at changing state forms and gathering better medical data on LGBTQ+ patients.

Quinn Gormley, co-executive director of MaineTransNet, which lobbied for several transgender rights bills passed this session, said advocates in her state were focused on how Maine could be a model of what’s possible.

“Our thinking before we got to session was, it’s important that we play defense, and we beat back against all the anti-trans bills — and we had a couple dozen here, all defeated,” she said. “But we didn’t want just playing defense to be the only thing that we did.”

Under one law, the state is conducting a review of all government forms to determine whether they need a gender field and, if so, whether to add a third, nonbinary option. Another law makes it easier for transgender people who transition after getting married to get new marriage certificates issued.

In Minnesota, lawmakers and advocates are looking into ways to plan for people moving into the state. Quade said the Legislature may consider appropriating funding for people who relocate there.

Hannah Edwards, executive director of the support group Transforming Families Minnesota, said advocacy organizations are teaming up to start collecting data to get a better sense of how many families are moving to the state. The goal is to gather enough information to show policymakers there is a need for more resources.

Transforming Families and other Minnesota-based groups have received emails from out-of-state families interested in the state’s efforts to serve as a safe haven. Out-of-state families have also started to join their Facebook groups and participate in their virtual peer support groups. Edwards said her team hopes to open more offices closer to its borders with states that are restricting transgender rights.

“It’s going to become increasingly important to not only support with the resources,” she said, “but also support those parents who are looking for connection when their state is hostile.”

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Arit John is a former staff writer for the Los Angeles Times, based in Washington, D.C. She joined the newsroom in 2020 as a political reporter covering the presidential campaign, then worked as a features and lifestyle reporter. John previously covered style at the New York Times, Congress and politics at Bloomberg News and breaking news at the Atlantic. She grew up in Rancho Cucamonga and studied English at UCLA.

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California Is First State to Adopt Sex Reassignment Surgery Policy for Prisoners

By Richard Pérez-Peña

Oct. 21, 2015

California has become the first state with a policy of providing sex reassignment surgery for some prison inmates, adopting a set of specific guidelines on what services it will provide to transgender prisoners, state officials and advocates for transgender people said.

The policy, which took effect this week, grew out of a pair of successful lawsuits filed by inmates. In one, a federal court in April ordered the state to provide surgery to a prisoner, which transgender advocates hailed as a landmark victory, but the inmate was paroled while that ruling was on appeal, making the point moot.

Then, after years of fighting such requests, the state settled the other case in August, agreeing to surgery for Shiloh Quine, a convicted murderer formerly known as Rodney J. Quine, who is serving a life sentence. California’s prisons already provided hormone therapy to transgender inmates, but experts said the Quine settlement was the first time any state had agreed to taxpayer-funded surgical reassignment for an inmate.

The new guidelines grew out of that settlement.

“California has set a model for the country,” said Kris Hayashi, executive director of the Transgender Law Center, a San Francisco-based group that represented the inmates in both cases. “This is care that, for too long, people have been denied simply because of who they are. It’s especially important because transgender people are incarcerated at six times the rate of the general population.”

Under the new policy, the state will cover mastectomies as well as operations to remove and reconstruct reproductive organs. But it will not cover services the state considers cosmetic, including breast implants or procedures or drugs for hair removal or hair growth.

A review committee of doctors and psychologists will decide whether to allow surgery, based on a prisoner’s physical and mental condition. And a request will be granted only if an inmate has more than two years left to serve before parole is expected; “has continuously manifested a desire to live and be accepted” with a particular sexual identity, including a desire for surgery, for two years; and has lived as a member of that sex, with hormone therapy, for a year.

“They’re pretty conservative criteria — the inmate doesn’t just request surgery and then get it,” said Joyce Hayhoe, legislative and communications director for the independent agency that oversees prison medical care.

The agency, California Correctional Health Care Services, is run by a court-appointed receiver who reports to a federal judge, under a 2002 court finding that medical services in the state’s prisons were inadequate. The new policy was drafted by that agency and the state Department of Corrections and Rehabilitation, which still controls prison mental health care.

It is not clear how many people will take advantage of the new policy. Most transgender people opt not to have surgery, while many others have breast surgery but not genital operations.

Out of 125,000 inmates in the California system, 400 are being treated for gender dysphoria, the condition of not identifying as the sex indicated by bodily organs, Ms. Hayhoe said. She said that gender reassignment operations and related care for one inmate could cost $50,000 to $100,000, compared with $500 to $3,000 a year for hormone therapy alone.

A string of lawsuits around the country has tried to push prison systems into recognizing gender dysphoria as a medical condition requiring particular accommodations, and in one case chronicled in The New York Times , the Justice Department weighed in, siding with the prisoner. Virginia and Georgia have both paroled inmates seeking surgery before their cases could be resolved in the courts.

Whether to provide surgery is not the only issue in such cases, nor is it the most basic. Some states have provided hormone therapy to transgender inmates, but others have not. And some house transgender prisoners according to the sex they identify as or make special arrangements for them, while others do not, which advocates say puts them at grave risk of being victimized.