UPDATE: The governor signed this bill on March 22. Original post follows.
Moving with unusual speed last week, Iowa Republican lawmakers approved Senate File 538, which broadly prohibits gender-affirming care, including puberty blockers, hormone treatments, and surgery, for Iowans under age 18.
During hours-long debates in the Iowa Senate and House, lawmakers raised points that would be central to litigation over whether banning gender-affirming care violates the constitutional rights of transgender children, their parents, and medical professionals.
For this post, I’ve pulled video clips to illustrate some of the core legal questions surrounding the bill. But there is much more of value in the passionate speeches delivered about Republicans’ latest attempt to target LGTBQ Iowans. You can watch the full Senate debate here (starting around 7:32:30) and the House debate here (starting around 1:40:45).
AT LEAST THREE POTENTIAL CONSTITUTIONAL CLAIMS
In Brandt et al v Rutledge et al, plaintiffs challenging the Arkansas ban on gender-affirming care for children filed a federal lawsuit alleging three violations of the U.S. Constitution:
- Equal Protection Clause (Fourteenth Amendment): the law discriminates against minors on the basis of their sex and transgender status.
- Due Process Clause (Fourteenth Amendment): the law restricts the fundamental right of parents to make medical decisions for their children.
- Free Speech (First Amendment): the law prohibits health care professionals from speaking about medically accepted treatments for gender dysphoria, and prevents patients and parents from hearing about those options.
A U.S. District Court issued a temporary injunction in August 2021, putting the Arkansas law, known as Act 626, on hold pending resolution of the lawsuit. A three-judge panel on the Eighth Circuit Court of Appeals, which includes Iowa, unanimously upheld the injunction in August 2022.
Senate File 538 is not identical to the Arkansas statute, but its goals and structure are similar enough to make the bill vulnerable to claims under the same constitutional provisions.
The bill prohibits various “gender transition procedure-related activities” for children, listing medications, hormone treatments, and surgeries that health care professionals cannot provide “if the practice is performed for the purpose of attempting to alter the appearance of, or affirm the minor’s perception of, the minor’s gender or sex, if that appearance or perception is inconsistent with the minor’s sex.”
Health care providers would be subject to discipline for “unprofessional conduct” by the relevant licensing board if they violated the state ban.
The bill allows the attorney general to enforce the prohibitions and allows other individuals, including parents of affected minors or former patients, to bring civil suits against health care professionals who provided gender-affirming care in violation of state law.
Senate File 538 would go into effect immediately if signed by the governor, but prohibitions on medications, hormones, or procedures would be applied beginning 180 days after the effective date. Republican State Senator Jeff Edler, who floor managed the bill, said the delay would give children “an essential off-ramp to let their bodies back off of the toxic drugs that they’re on.”
The Iowa Senate approved the bill along party lines on March 7. House members passed the bill by 58 votes to 39 the next day, with five Republicans (Chad Ingels, Megan Jones, Shannon Latham, Brian Lohse, and Hans Wilz) joining all Democrats to oppose the measure. Republican Michael Bergan later put a note in the House Journal explaining that he too had intended to vote no.
“THIS IS TARGETING A SPECIFIC GROUP OF PEOPLE”
To prove an equal protection violation, plaintiffs challenging Senate File 538 would need to show the law treats certain patients differently from others receiving the same medications or procedures.
Early in the Senate debate on March 7, Democratic Minority Leader Zach Wahls zeroed in on an unusual section of the bill, which states, “Compliance with, or enforcement or implementation of, this section shall not constitute a violation of any provision of chapter 216.”
Chapter 216 is the Iowa Civil Rights Act, which has prohibited discrimination on the basis of gender identity since 2007. Wahls asked Edler to explain why the bill contains that language.
Edler said, “This is a public health concern. This has nothing to do with civil rights of Iowans, period.”
But the bill restricts what health care people can access based on their gender identity, Wahls pressed.
Edler said it was “based on the long-term effects of the procedures” used on minors, later claiming “the dosing levels to get those results is what creates the public health situation.”
Wahls kept trying to get Edler to acknowledge that the bill allows children to have access to these medications and procedures if they are not seeking them for gender transition reasons. He noted that puberty blockers are routinely prescribed for other conditions to kids who are not transgender.
So just to be clear, that’s why you feel it’s important to specify that this is not in violation of the civil rights act. Because this is targeting a specific group of people. It’s targeting only those minors who are receiving this care for this specific purpose.
Edler appeared confused at times but did not concede the point. “This is a prohibition under the public health chapter of Iowa. Not the civil rights chapter.”
“Well then why are we talking about the civil rights chapter?” Wahls asked.
In further discussion, the floor manager would not admit the bill targets transgender people. He characterized it as applying to “all minors who are seeking puberty blockers under gender transition.”
“Are there any minors trying to undergo gender transition who aren’t transgender?” Wahls asked. “I have no idea,” Edler said.
IS SUICIDE PRIOR TO TRANSITIONING “A LONG-TERM EFFECT”?
To persuade a court to block Senate File 538 from being enforced pending litigation, plaintiffs would need to show they are likely to succeed on the merits of case, and they would suffer “irreparable harm” in the absence of an injunction.
To that end, many House and Senate Democrats emphasized that major medical associations endorse gender-affirming care, and cited statistics on how such care reduces suicidal thoughts and suicide attempts among transgender youth.
Since Edler had presented the bill as a public health measure, Bennett began by asking about the leading causes of death for kids under age 19. When Edler challenged the relevance of that data, Bennett explained, “it’s been established that there’s a suicide risk with transgender kids that this bill directly impacts.” Suicide is the second leading cause of death for children, adolescents, and young adults.
Edler characterized the bill as prohibiting “experimental procedures on Iowa children.” But Bennett cited statistics relating to high rates of suicidal ideation and attempts among transgender people.
The Republican dismissed those findings as being from a “short-term study.” He said he was concerned about “long-term effects” from medications and procedures.
In one of the most striking moments from the debate, Bennett followed up: “Would you consider committing suicide prior to transitioning to be a long-term effect?” After an awkward silence, she told Edler he didn’t have to answer.
The Democrat wrapped up that part of her remarks by emphasizing,
I’m not aware of any other laws that deny recommended care by major medical organizations to a particular group of people who are at a special risk of death. Only transgender people. Only transgender people have laws being made about their care, which impact their ability to live on this planet. Just trans people.
Note: LGBTQ youth struggling with thoughts of self-harm can reach trained counselors through the Trevor Project, which offers text, phone, or chat services. Readers experiencing suicidal thoughts for any reason can call 988 or (855) 581-8111, text (855) 895-8398, or use the live chat function on the Your Life Iowa website.
“WHY DO YOU WANT TO STRIP ME OF MY LIBERTY AND MY FREEDOM AS A PARENT?”
The Arkansas plaintiffs include several transgender children and their parents, who would be denied access to medically necessary care if the law were enforced. While no Iowans have announced plans to challenge Senate File 538 in court, House and Senate Democrats read out numerous messages they had received from Iowans who worried the bill would devastate their families.
Any of those parents or children would have standing to challenge a ban in Iowa, since they would potentially suffer the same irreparable harm from losing access to gender-affirming care.
I chose to include this video of State Representative Amy Nielsen, because Karen Butler, the mother of a nonbinary child, came to Des Moines to testify at the House and Senate subcommittees in February. Butler told lawmakers the bill was not only a threat to LGBTQ youth, but also “a stunning and egregious threat to parental rights.”
Nielsen knows this family well; one of her own children is a close friend of Butler’s child.
Excerpts from Butler’s statement:
My child was assigned female at birth, and late last year, at the age of 16, they received gender affirming top surgery.
You need to understand that our journey to that day of surgery was not a rash or impulsive one. It was weeks that turned into months that turned into years of extensive conversations with our child and hearing their experience, and understanding their distress. It involved multiple consultations with primary care and specialty physicians as well as mental health professionals. In the end, my husband and I made what we believed to be the best choice for our child.
With the onset of puberty, my child realized that their developing body had begun to betray them, despite wishing for years—literally, as far back as they can remember—that maybe, somehow, their body would fail to develop breasts.
Instead, as their body inevitably did develop, they were wracked with a torment of feeling trapped inside a body that was not really theirs. They began to withdraw, physically and emotionally. They experienced severe gender dysphoria and all the emotions that come with that. They suffered from depression and anxiety and disordered eating because of the harsh disconnect between who they knew they were and how they felt in their body.
In response, we did what any loving parents would do. We sought professional help. We read volumes. We had a huge learning curve. I understand that the immensity of a procedure like gender-affirming top surgery is difficult for many people to understand. And I assure you this was not something we went into lightly. We talked to the professionals who follow the peer-reviewed science and evidence-based best practices that have been adopted around the globe. We talked to our child, we listened to our child, and we trusted our child. Ultimately, we knew it was the right thing to do for our child. And in the end, it was our sacred and legal duty as parents to make that decision. And we made that choice.
Alluding to the school voucher plan the Iowa legislature approved earlier this year, Butler noted that Republicans had “argued that parents should be the ones to decide what is best for their children.”
Why does this same rationale for parental rights not apply here? Why do you want to strip me of my liberty and my freedom as a parent? How is this legislature in a better position than I to make health care decisions for my child?
You are not. You do not know my child. You did not hold my child when they were sick with pneumonia on their first birthday; you did not drive them to the hospital when they had appendicitis and needed surgery; you were not there to beg them to keep living and promise them that things would get better. My husband and I were, and we are in the best position to help make informed decisions about our child’s health and well-being, in consultation with their health care professionals.
I want you to understand that the gender affirming surgery my child received was medically necessary—potentially lifesaving—care.
You also need to know that this legislation will cause harm to vulnerable youth even by the very act of proposing it. It says to them they are not worthy; that who they are is not valid; that there is something wrong with them for the very way they experience who they are in the world.
Nielsen added that she strongly agrees with Butler on this point: “I firmly reject that notion and want our LGBTQ youth to know they are not alone, their feelings are valid, and they deserve to receive the health care they need, and I—and all of us—will continue to fight for them.”
Nielsen then read a statement from Butler’s child Ridley. “Before I had my surgery, I couldn’t look at myself without getting angry or having to hold back tears.” Whenever they saw their reflection, they were overcome with emotion.
“Some may say it’s unnatural to permanently alter my body,” Ridley wrote. “But I say it’s unnatural to drive kids to stop eating during the most important developmental years of their lives, because they think it might give them the flat-chested look that they crave.”
Ridley added, “I no longer cry myself to sleep, or lose focus in class worrying about how big my breasts are, and that I don’t look enough like a boy. My gender-affirming care saved me from body dysmorphia, disordered eating, and depression. It saved my life.”
Nielsen was visibly angry as she ended her speech. “I cannot imagine a future without Ridley. They are an amazing young person, strong and brave and full of fight. I want you remember Ridley when you go to press that button this afternoon.”
To be clear: I don’t know who may step up to challenge Iowa’s law, assuming the governor signs Senate File 538. But there will be families with stories to tell that are much like Karen Butler’s and Ridley’s.
“THESE ARE THE LIVES OF IOWANS”
One Iowa lawmaker is the parent of a transgender child, and Democratic State Representative Ross Wilburn made that experience the focus of his speech on March 8. Excerpt:
Wilburn’s son James is now an adult and no longer lives in Iowa. But as Wilburn described his journey, in part chronicled by the Iowa City Press-Citizen in 2018, he reminded colleagues, “bills like this do take away freedom from Iowans to be who they are, and from their parents to make health care life-saving decisions for their children.”
James believes the top surgery he had at age 21 saved his life, removing a weight that went beyond the physical. He remembers getting his first testosterone shot and experiencing a “feeling of aligning with myself.”
Wilburn recalled a high school friend of his child’s, who was also transgender and ended up taking his own life. “These are the lives of Iowans that voting yes for this will put at risk.”
“THEY SHOULD BE FREE TO MAKE THAT DECISION FOR THEIR KID”
As mentioned above, six Iowa House Republicans opposed Senate File 538. Those who explained their positions on the floor highlighted the potential infringement of parents’ rights.
Here’s part of State Representative Brian Lohse’s remarks. He and Megan Jones also voted against the bill when it was before the House Judiciary Committee.
Lohse referred to the amendment Jones had proposed in committee and again on March 8, to give parents the right to make decisions regarding their child’s medical care. (The speaker somehow determined that amendment was not germane to the bill, and Jones’ motion to suspend the rules to allow a vote on it failed.)
“Whether we like or agree with that decision or not, they should be free to make that decision for their kid,” Lohse said. He’d never faced this kind of situation and didn’t know how he would react, “but it’s not my job as a legislator, certainly not my job as a human to judge them in the rightness or wrongness of that decision.”
Lohse added that the bill had another major problem: it doesn’t allow children “who have already started this process” to continue their medical care. His understanding is that stopping some of this care “can actually have more harmful effects than continuing it.”
Finally, Lohse mentioned the litigation over the Arkansas statute. “As soon as the ink is dry,” Iowa’s law would be challenged and likely enjoined. “So all we’re doing today is needlessly ginning up a lot of controversy, a lot of discussion, when all we have to do really is wait and see what happens with the Arkansas case.”
“IF THEY THINK DIFFERENTLY THAN WE DO, TO HELL WITH THEM”
The other Republican to speak against the bill was Chad Ingels. He began by saying he never expected to feel compelled to talk about this topic, but feels empathy for families with a transgender child, because of his experience as a father to two children with disabilities.
“I was raised not to judge other people,” Ingels continued. “And we do a lot of judging of people in this building.”
Focusing on one “extremely small population of people” with this bill “is sad for me. I think it’s sad for a lot of Iowans. It’s nothing anybody back home talked to me about. Zero conversation about this in the last three years that I’ve been in political life in Iowa.” Whereas “Iowans want to be able to go about their business, live their life,” this bill “seeds division.”
Like several Democratic lawmakers who had already spoken, Ingels recalled that Republicans have talked a lot during this legislative session about making parents the focus. But not when “those parents think differently than us, evidently. If they think differently than we do, to hell with them. Their kids aren’t going to be happy until they turn 18, or later.”
Ingels concluded by saying, “I want the people of Iowa to know that not everybody in the majority party in this capitol is going to vote for this bill, believes in this bill.” He believes “everybody should get the opportunity to be happy, live their life, and that the parents should make the choice in this situation.”
“AN INVASION OF THE DOCTOR PATIENT RELATIONSHIP”
The Arkansas plaintiffs include a pediatric endocrinologist and an OB/GYN who would face a difficult choice: failing to provide medical care in accordance with accepted standards, or risking consequences such as losing their licenses to practice medicine.
Any health care professional who now provides gender-affirming care to Iowa youth would likely have standing to bring a similar case.
No one in Iowa’s medical community has announced plans to challenge Senate File 538, but many urged legislators not to pass the bill. Those included written comments from various practitioners of psychiatry, psychology, family medicine, pediatrics, and behavioral health, and in-person testimony from Dr. Katie Imborek, co-director of the University of Iowa LGBTQ+ clinic, Dr. Marianka Pille, president of the Iowa Chapter of the American Academy of Pediatrics, and Dr. Kaaren Olesen, an OB/GYN with years of experience providing gender-affirming care to adolescents.
Pille told members of an Iowa Senate subcommittee that the proposal “represents an invasion of the doctor patient relationship and ignores the fact that gender-affirming care is standard health care, life-saving health care, that is nuanced and individualized to meet the specific needs of a patient.”
Olesen listed some of the medical associations that endorse gender-affirming care, adding that her governing body, the American College of Obstetricians and Gynecologists, “supports the use of evidence-based resources, care, and information for individuals, including adolescents, accessing gender-affirming care and transition therapy, free from political interference.”
Imborek told members of the House Government Oversight Committee last month that “puberty blockers are fully reversible, and cross-sex hormone therapy is partially reversible,” the Des Moines Register reported. In her experience, the small number of patients who stop taking hormones “do not regret receiving that care.”
Asked about the impact of a state ban on these treatments for children, Imborek said, “I worry about that every day. I probably worry most that my patients who already started down this path who are minors, that this would be really devastating for them.”
On a related note, Democratic State Representative John Forbes, who is a pharmacist, questioned Republican floor manager Steven Holt about how the bill might affect members of his profession. Could an Iowa pharmacist fill a prescription if the parent of a transgender child went to another state to receive gender-affirming care?
Holt said he would not go down the road of discussing “hypothetical scenarios,” telling Forbes, “You can read the bill, you can see what the bill says.” (The bill mentions “health care professionals” but not pharmacists specifically.)
Holt also refused to answer Forbes’ question about potential consequences for a parent who gets a prescription for puberty blockers or cross-sex hormones filled in another state and brings the medication back to Iowa.
“THIS LAW VIOLATES MY FREEDOM OF RELIGION”
The Arkansas plaintiffs have argued in court that the state law unconstitutionally restricts their free speech.
Those who drafted Senate File 538 made some effort to preempt such claims. The section prohibiting health care professionals from aiding and abetting various gender transition related procedures includes this sentence: “This paragraph shall not be construed to impose liability on any speech protected by federal or state law.”
State Senator Janice Weiner, who is Jewish, pointed to another possible avenue for a First Amendment challenge. From her speech during the Iowa Senate debate:
Weiner explained how rabbinic writings in the Talmud identify six genders. “The rabbis understood that gender was a spectrum.” She went on to outline a Jewish perspective on “affirming and supporting the gender identity of a person.” In part, that stems from the commandment to prioritize saving a life. “When a population is predisposed to suicide, you help them. You do what it takes to affirm and protect their lives, because their lives come first.”
The Conservative and Reform denominations of Judaism “overwhelmingly support transgender rights,” Weiner added. “Judaism accepts and affirms transgender individuals, full stop.”
All Iowans have a constitutional right to our own religious beliefs, but none of us can pass a law imposing our personal religious beliefs on others. “This law violates my freedom of religion under the Iowa Constitution.”
Finally, Weiner argued that the bill is “too vague,” because it “does not make clear that religion-based male circumcision, which is practiced by Jews and Muslims alike, is permissible. That too is a freedom of religion issue.”
Senate File 538 bans surgical procedures on minors to remove “any healthy or non-diseased body part or tissue.” The bill’s sponsors (including Holt during the House subcommittee) have denied that language would prohibit circumcision. But the bill does not mention that practice. Its list of exemptions mostly concern children with intersex characteristics, or various illnesses, injuries, or disorders that might require medical procedures—not any surgeries rooted in religious observance.
There could be grounds for a Jewish family with a transgender child, or for a Jewish physician providing gender-affirming care to children, to challenge the Iowa ban as an infringement of religious freedom. The lobbyist declarations show no medical, public health, or child advocacy groups support the bill. Almost all the entities lobbying for the ban are Christian or Catholic organizations.
THE STATE’S DEFENSE: “THE PROTECTION OF OUR CHILDREN”
While advocating for the bill, Holt and Edler previewed arguments the state would make to defend Senate File 538 in court. Their central point was that they are not trying to discriminate against anyone—only seeking to protect children from dangerous procedures.
I pulled this clip because Holt was more articulate and adept than Edler. Democratic State Representative Brian Meyer repeatedly tried to pin his adversary down on singling out a group. (“Doesn’t this bill restrict what health care someone can access based on their gender?”) Every time, Holt pivoted to the supposed medical evidence questioning the safety and efficacy of “experimental treatments” like puberty blockers and hormones.
The lobbyist declarations reflect the overwhelming consensus of the mainstream U.S. medical and psychological community against restricting gender-affirming care. To counter that point, Holt repeatedly cited policies implemented in countries such as Sweden, Britain, France, Australia, and New Zealand.
Pressed for evidence to back up his claim, Holt cited a long-term study from Sweden showing that people who had gender reassignment procedures were 19 to 20 times more likely to take their own lives compared to peers who were not transgender. Holt said the Obama administration reached the same conclusion in 2016 when it declined to mandate that Medicare plans cover gender-affirming surgery.
The Republican also cited updated guidelines from the Swedish Institute regarding hormonal treatments for minors with gender dysphoria, warning of irreversible “adverse consequences” such as cardiovascular disease, osteoporosis, infertility, increased cancer risk, and thrombosis. “This makes it challenging to assess the risk/benefit for the individual patient, and even more challenging for the minors or their guardians to be in a position of an informed stance regarding these treatments.”
Holt said the British National Health Service had recently changed its position on puberty blockers, saying “little is known” about the long-term effects in children with gender dysphoria, or possible impacts on the teenage brain or children’s bones. Holt said medical societies in other countries were moving away from “medicalization” of treatment of children with gender dysphoria.
Meyer tried to get back on track: “Can you think of anyone aside from transgender people that would need gender-affirming care?”
Holt insisted, “We are doing this for the protection of our children,” because Republicans don’t think there can be “informed consent.”
Since Iowa Republicans have often championed parents’ rights, Meyer asked whether Holt agreed that most decisions for children should be made by their parents in consultation with doctors.
Holt said that “depends upon the situation,” but it doesn’t apply to this situation, again because of the “lack of informed consent.” He said doctors who recently testified before the Iowa House Government Oversight Committee acknowledged they don’t track the children they treat for gender dysphoria into adulthood.
FEDERAL COURT FOUND PURPORTED HEALTH CONCERNS NOT “GENUINE”
The state of Arkansas advanced similar arguments to defend its ban, but the U.S. District Court was not convinced. In an August 2021 opinion explaining its decision to put the law on hold pending litigation, the court determined the state’s purported desire to protect children from experimental treatment was “pretextual.”
If the State’s health concerns were genuine, the State would prohibit these procedures for all patients under 18 regardless of gender identity. The State’s goal in passing Act 626 was not to ban a treatment. It was to ban an outcome that the State deems undesirable. In other words, Defendants’ rationale that the Act protects children from experimental treatment and the long-term, irreversible effects of the treatment, is counterintuitive to the fact that it allows the same treatment for cisgender minors as long as the desired results conform with the stereotype of their biological sex.
The District Court cited various U.S. Supreme Court precedents affirming a fundamental right of parents to make decisions for their children, including directing medical care. The state would need to demonstrate some compelling governmental interest to justify limiting that fundamental right and show the ban on gender-affirming care was “narrowly tailored to serve that interest.”
But the court found, “The goal in this context is pretextual because Act 626 allows the same treatments for cisgender minors that are banned for transgender minors as long as the desired results conform with the stereotype of the minor’s biological sex.”
Importantly, the District Court determined the Arkansas law likely “could not withstand either heightened scrutiny or rational basis review” when considered on the merits. Rational basis is the lowest bar for the government to clear, requiring only that the state demonstrate some legitimate interest in the policy or law being challenged.
The Eighth Circuit panel’s August 2022 opinion upholding the injunction on the Arkansas law included some passages that should concern Iowa Republicans.
Arkansas’s characterization of the Act as creating a distinction on the basis of medical procedure rather than sex is unpersuasive. Arkansas argues that administering testosterone to a male should be considered a different procedure than administering it to a female because the “procedure allows a boy to develop normally” whereas for a girl it has the effect of “disrupting normal development.” But this conflates the classifications drawn by the law with the state’s justification for it. The biological sex of the minor patient is the basis on which the law distinguishes between those who may receive certain types of medical care and those who may not. The Act is therefore subject to heightened scrutiny.
Whereas “Arkansas complains the district court failed to consider the medical evidence it submitted,” the Appeals court panel found “no clear error in the district court’s weighing of the competing evidence” from scientific literature and medical experts.
Additionally, there is substantial evidence to support the district court’s conclusion that the Act prohibits medical treatment that conforms with the recognized standard of care. Even international bodies that consider hormone treatment for adolescents to be “experimental” have not banned the care covered by Act 626.
Holt and Edler asserted that all children should have the opportunity to go through natural puberty, and claimed many would identify with their gender assigned at birth if not given puberty blockers. But the Eighth Circuit panel didn’t view forced puberty as a benefit for affected teenagers.
In considering the risk of irreparable harm to the Plaintiffs, the district court found that if Act 626 went into effect, Minor Plaintiffs would be denied access to hormone treatment (including needing to stop treatment already underway), undergo endogenous puberty—a process that cannot be reversed—and suffer heightened gender dysphoria. These factual findings are supported by Minor Plaintiffs’ affidavits and are not clearly erroneous. The findings support the conclusion that Plaintiffs will suffer irreparable harm absent a preliminary injunction.
The ACLU of Iowa, which has represented plaintiffs in other cases involving transgender discrimination, had no comment for the record on the constitutionality of Iowa’s proposed ban on gender-affirming care for minors. (The ACLU of Arkansas is representing plaintiffs in the Brandt case.)
Lambda Legal, a nonprofit advocating for the civil rights of LGBTQ people, has submitted an amicus brief in support of the Arkansas plaintiffs. Prior to final passage in the Iowa House and Senate, Lambda Legal’s Senior Attorney Kara Ingelhart provided this comment to Bleeding Heartland on our state’s proposed ban: “any law that would restrict a young person’s access to gender-affirming healthcare care interferes with mainstream, accepted standards of health care provision. Such bans on health care are also unlawful and unconstitutional.”
Top image: A protester holds a sign in support of gender-affirming care at a March 5 rally outside Iowa’s state capitol. Photo provided by Progress Iowa and published with permission.