Alabama Anti-LGBTQ Legislation: What Could Happen Next

Katie doesn’t want to leave Alabama. At 15 years old, she has lived in Alabama her whole life. It’s home.

She may soon have to. On April 8, Republican Governor Kay Ivey signed a law banning doctors from providing gender-affirming medical care to young people—care that trans youth like Katie rely on. The law includes an unusual provision causing it to go into effect in 30 days, meaning that come May 8, Katie’s doctors will no longer legally be allowed to continue her medical care.

“I just want to be able to live my life without having to worry about lawmakers taking away my medical treatment,” says Katie, who TIME is referring to by a pseudonym because she fears discrimination in her community for being trans.

Alabama’s new ban on gender-affirming medical care is the most extreme in the country. While Arkansas and Texas have also restricted such treatment, only Alabama has made it a felony for medical doctors to provide gender-affirming care to anyone under 19—punishable by up to 10 years in prison. Ivey also signed another bill that prohibited trans students from using school facilities that were sex-segregated, like bathrooms, that align with their gender identity. That legislation also included a modified version of Florida’s so-called “Don’t Say Gay” law, which went further than the original by banning all “classroom discussion” of sexual orientation or gender identity in grades K-5. Both restrictions are set to go into effect in July, and come on the heels of last year’s Alabama law prohibiting trans athletes from playing on the sport teams aligned with their gender identity.

Alabama, in simple terms, is the center of all laws that target LGBTQ youth. “It’s taking every form of anti-trans legislation, and really taking it up to 11,” says Kaitlin Welborn, staff attorney at the ACLU of Alabama.

Alabama might be the epicenter of these kinds of laws. However, this effort is part a larger nationwide trend in anti-LGBTQ legislation. According to NBC News, at least 238 anti LGBTQ bill bills have been introduced by conservative state legislators in 2022. This is almost half of the total number. 15 states have prohibited trans students from participating in sports that are compatible with their gender identity. Alabama has passed the first felony law restricting gender-affirming health care. Similar bills are currently in 18 states. While litigation is ongoing, the ACLU has filed lawsuits against Arkansas and Texas over similar bans. Chase Strangio, the deputy director for transgender justice at the ACLU LGBTQ & HIV Project, says he expects states with trans sports bans will continue to try to escalate to other forms of restrictions.

Continue reading: Trans youth are being hounded more often by pediatricians. The Line Could Provide Lifesaving Care

Alabama’s laws are already meeting legal challenges. In the last week, two lawsuits have been filed to stop the ban on youth-affirming gender care. Alabama’s LGBTQ youth could be affected by the outcome of these lawsuits. It could also impact other states, as the results of similar challenges could indicate whether laws in the rest of the country will remain or fall.

Meaning that the choice facing Katie’s family—whether they need to leave their home so their child can continue accessing affirming medical care—could soon be facing many more.

Legal battles are on the rise

In a letter sent to all state attorneys on March 31, the U.S. Department of Justice said bans on gender-affirming care may violate the Constitution, particularly the 14th Amendment’s equal protection and due process clause. This was an open letter to all state attorneys on March 31. It represented a strong statement by the executive branch regarding the subject.

Now, litigation over Alabama’s new law will shine a light on whether federal judges agree.

The ACLU, along with Lambda Legal, Transgender Law Center, and the law firm Cooley LLP filed one of two major lawsuits this week attempting to block Alabama’s ban from taking effect, arguing it violates the Constitution. (Welborn says they’re keeping “all legal avenues open” in terms of challenging the other restrictions, but are primarily focusing on the medical ban due to the unusually swift enforcement and extreme criminal penalty.) The second lawsuit was brought by the Southern Poverty Law Center, the National Center for Lesbian Rights (NCLR), GLBTQ Legal Advocates & Defenders, and the Human Rights Campaign with the firms King & Spalding LLP and Lightfoot, Franklin & White LLC.

Both lawsuits argue that Alabama’s ban on gender-affirming care violates the Equal Protection Clause by discriminating against transgender people and infringes on parents’ rights to follow a medical professional’s advice on what’s best for their child.

“There are very real challenges facing our young people, especially with today’s societal pressures and modern culture. I believe very strongly that if the Good Lord made you a boy, you are a boy, and if he made you a girl, you are a girl,” Alabama Gov. Ivey made the statement April 8 in a press release. “We should especially protect our children from these radical, life-altering drugs and surgeries when they are at such a vulnerable stage in life. Instead, let us all focus on helping them to properly develop into the adults God intended them to be.” (It’s rare for a person under age 18 to undergo any type of surgical intervention, according to The American Academy of Pediatrics.)

Dr. Morissa Ladinsky, a pediatrician at UAB Medicine in Birmingham who works with trans youth from Alabama and surrounding states, is a plaintiff in NCLR’s lawsuit challenging the new policy. This lawsuit claims the law is contrary to Article VI’s supremacy clause. Article VI states that federal law preside over state law. Ladinsky’s hospital receives federal funding, meaning it must adhere to the Affordable Care Act, the legal team argues. Discrimination on the grounds of sexual orientation and gender identity is prohibited by the Affordable Care Act. Ladinsky must now choose whether to follow federal law, or risk 10 years imprisonment and lose federal funding.

These arguments will influence how the court responds. While the litigation won’t impact other states unless it reaches the appeals level, the results in Alabama could still be persuasive for other states and lawmakers watching as they consider drafting their own laws, says Asaf Orr, senior staff attorney at NCLR, and for the lawyers in turn deciding how to file the lawsuits.

When asked to comment on the lawsuits, Ivey’s communications director Gina Maiola said their office is “prepared to defend our values and this legislation.”

‘Forces our hand to actually do harm’

Jeff Walker, five years ago Jeff Walker said that his daughter used to be quiet and reserved. Now, since she’s begun gender-affirming care, she is confident, outgoing, and courageous, he says.

“She is who she is meant to be today,” Walker says. “And it’s because of starting off with this wonderful team of doctors and having the support of her family.”

Walker and his wife Lisa are plaintiffs in the ACLU’s lawsuit challenging Alabama’s felony ban on affirming care. The ban is a violation of their rights to make best medical decisions about their daughter, who is 15 years old.

Gender-affirming care can help young people experiencing gender dysphoria, which is often described as the discomfort or distress that might occur when a person’s gender identity is inconsistent with the sex they were assigned at birth, according to the Mayo Clinic. Non-medical behavioral and social interventions can help young children with gender dysphoria. After puberty has begun, a child experiencing gender dysphoria may also begin receiving puberty blockers, which can help “reduce distress that may occur with the development of secondary sexual characteristics” and reduce the need for surgery in the future by holding off physical changes, according to the American Academy of Pediatrics. As they age, many adolescents will begin to take gender-affirming hormones such as estradiol or testosterone.

Research has shown that affirming models of care can reduce mental health issues for young trans and gender diverse people. The peer-reviewed paper was published in the Journal of Adolescent Health The use of gender affirming hormone therapy, which is delivered to trans and nonbinary young people, was associated with lower suicide rates, suicidal ideation and depression. This finding was made in December 2021. The Trevor Project suicide prevention organization conducted the study. It also revealed that transgender youth under 18 had nearly 40 percent lower chances of making a suicide attempt within the previous year. The American Medical Association and American Psychological Association have condemned the ban on gender-affirming treatment.

“Pediatricians are dedicated to the well-being of all children. Laws like these directly interfere with their ability to keep their patients healthy and provide evidence-based care,” Mark Del Monte, the CEO of the American Academy of Pediatrics, said in an April 7 statement. “This legislation targets vulnerable young people and puts them at great risk of physical and mental harm.”

Alabama’s new law has no grandfather clause that exempts young people who are already receiving affirming care. Meaning that, come May 8, Ladinsky—the pediatrician who treats trans youth in the state—can’t treat any of her patients, even older adolescents who might have been on puberty blockers or hormone replacement therapy for years. “Forcing us to cease care that’s already ongoing and successful… not only does it violate a major tenet of medical ethics that we all took an oath to uphold, but it also forces our hand to actually do harm,” Ladinsky says. “Youth who were on an amazing trajectory from really dark places may well be catapulted backward… That fallout on mental health is terrifying.”

Katie’s mother and Walker have both assured their daughters that if they need to leave the state to get their care, they will. But that’s no simple decision for families that have deep ties and other commitments in their home state; Walker’s son, for example, is in the middle of a 3.5-year commitment with the Alabama National Guard. “These legislators say they’re protecting the family,” Walker says. “They are doing nothing but splitting families up and making them have to make decisions that they don’t want to make.”

Katie’s mother and Katie are currently considering whether Katie should be taken out of second year at high school, away from their families and friends. “Honestly,” Katie says, “I’m a little scared.”

Send an email to Madeleine Carlisle at madeleine.carlisle@time.com.