West Virginia Republican Gov. Jim Justice on Wednesday signed a bill banning gender-affirming care for minors, joining at least 10 other states that have enacted laws restricting or outlawing medically supported treatments for transgender youth.

The bill outlaws those under 18 from being prescribed hormone therapy and fully reversible puberty blockers. It also bans minors from receiving gender-affirming surgery, something physicians say doesn’t even happen in West Virginia.

Unlike measures passed in other states, however, West Virginia’s law contains a unique exemption: It permits doctors to prescribe medical therapy if a teenager is considered at risk for self-harm or suicide.

Under the law, which will take effect in January 2024, a patient can be prescribed puberty blockers and hormone therapy after receiving parental consent and a diagnosis of severe gender dysphoria from two clinicians, including a mental health provider or an adolescent medicine specialist.

Both practitioners must be trained to diagnose and treat young people with severe gender dysphoria and provide written testimony that medical interventions are necessary to prevent or limit possible or actual self-harm.

The provisions were added at the urging of Senate Majority Leader Tom Takubo, who is a physician.

“These kids struggle. They have incredible difficulties,” the Republican said on the Senate floor earlier this month. Takubo cited more than a dozen peer-reviewed studies showing a decrease in rates of suicide ideation and attempts among youth with severe gender dysphoria who had access to medication therapy.

Gender dysphoria is defined by medical professionals as severe psychological distress experienced by those whose gender identity differs from their sex assigned at birth.

The bill also prohibits minors from being prescribed hormone therapy before the age of puberty, something West Virginia physicians say doesn’t happen anyway.

The medication dosage for any adolescent must be the lowest possible necessary to “treat the psychiatric condition and not for purposes of gender alteration,” according to the bill.

Widespread GOP Effort

The West Virginia law comes as Republican lawmakers across the U.S. have pursued several hundred proposals this year to push back on LGBTQ+ rights, particularly rights for transgender residents, including banning transgender girls from girls sports, keeping transgender people from using restrooms in line with their gender identities and allowing or requiring schools to deadname trans students.

Lawmakers in West Virginia and other states moving to enact bans on transgender health care for youth and young adults often characterize gender-affirming treatments as medically unproven, potentially dangerous in the long term and a symptom of “woke” culture.

Every major medical organization, including the American Medical Association, the American Academy of Pediatrics and the American Psychiatric Association, supports gender-affirming care for youths.

A 2017 study by UCLA Law’s The Williams Institute estimated West Virginia had the highest per capita rate of transgender youth in the country.

The rate of suicide ideation, or having suicidal thoughts or ideas, for transgender youth in West Virginia is three times higher than the rate for all youth in the state, according to West Virginia Youth Risk Behavior Survey data.

Natalie Frazier, who oversees gender-affirming care for Planned Parenthood in North Carolina, South Carolina, Virginia and West Virginia, said the bill Justice signed Wednesday was “better than it could have been.”

“But it’s still unnecessary — just an unnecessary barrier to care that is going to end up harming people,” she said, adding that not every child’s family will have the resources to travel to two different clinicians for a gender dysphoria diagnosis.

Frazier, who is also a certified nurse midwife, said the diagnosis of severe gender dysphoria with risk of suicide “could probably apply to just about any kid getting access to gender-affirming care.”

“That’s why people are are so invested in providing the care because there is a disproportionate risk,” she said. “That’s something that any of these kids could be at risk for and nobody’s going into this care lightly.”

West Virginia’s ban also includes exemptions for people who are born intersex and for people taking treatments for infection, injury, disease or disorder that has been “caused by or exacerbated by the performance of gender transition procedures.”

Surgeries can be performed if a child is at risk for “imminent danger of death or impairment of a major bodily function.”

At least 11 states have now enacted laws restricting or banning gender-affirming care for minors: Alabama, Arkansas, Arizona, Georgia, Iowa, Kentucky, Mississippi, Tennessee, Utah, South Dakota and West Virginia. Federal judges have blocked enforcement of laws in Alabama and Arkansas, and nearly two dozen states are considering bills this year to restrict or ban care.