Late Tuesday night, the Associated Press projected Ohio Republican Bernie Moreno defeated Democratic incumbent Sen. Sherrod Brown—and with him, any sense that Ohio was still a swing state.

Brown, who served three terms, maintained an edge for most of his US Senate reelection bid against Moreno, a former luxury car dealership owner from Colombia. But in the end, a windfall of cash from national Republican groups boosted Moreno over the top. Just before midnight, Moreno lead Brown by 5 points.

It’s not surprising that a Republican would win a Senate seat in Ohio, but the fact that this particular Republican beat a well-liked incumbent suggests how much Ohio has changed in less than a decade.

As a Rust Belt state devastated by deindustrialization, automation, and in recent years, an epidemic of drug addiction, Ohio tends to gravitate toward candidates who are dutiful in their support for middle-class and working-class voters. But Moreno doesn’t have a pro-worker reputation: As we previously reported, he was found liable for withholding wages from employees and was sanctioned by a judge for disposing of documents relevant to that case. He additionally faced lawsuits from former employees who accused him of racial, gender, and age discrimination. More recently, he’s blocked voters from recording his events by using audio jammers.

Moreno also struggled to refine his message on reproductive rights, a topic 57 percent of Ohio voters said they supported in 2023 when they approved a ballot measure enshrining abortion access. “You know, the left has a lot of single issue voters,” Moreno said in a leaked video from a recent town hall. “Sadly, by the way, there’s a lot of suburban women, a lot of suburban women that are like, ‘Listen, abortion is it. If I can’t have an abortion in this country whenever I want, I will vote for anybody else,'” Moreno mocked. “OK. It’s a little crazy, by the way, but—especially for women that are like past 50, I’m thinking to myself, ‘I don’t think that’s an issue for you.'”

But Moreno did have something Brown could never dream of—nor desire: an endorsement from Donald Trump. That endorsement was likely pivotal for Moreno, says Paul Beck, professor emeritus of political science at Ohio State University. It gave him the edge against state Sen. Matt Dolan, a more traditional Republican who was Moreno’s biggest competition in the primary race. With no political experience and, until recently, not much name recognition, “he doesn’t really have a strong track record” otherwise, Beck says.

While Brown is a political progressive—supporting LGBTQ rights and reproductive freedoms—he has maintained a healthy distance from the rest of his party in recent months. He didn’t campaign with Harris. He stayed home this summer while fellow Democrats threw their celebratory, celebrity-filled nominating convention in Chicago. Brown also garnered the endorsement of the only Republican who ever defeated him in an election: former Ohio Gov. Bob Taft, who bested Brown as he sought reelection as Ohio’s secretary of state in 1990.

Known for sporting union-made suits and driving union-made cars, Brown’s 2024 campaign also attracted long-standing appreciation from prominent labor union leaders. The senator often wears a canary pin on his lapel to symbolize 20th-century coal miners who were subjected to dangerous working conditions before collective bargaining advanced job safety.

His populist persona and these contradictions are the same ones that helped Brown win the Senate seat three times in 2006, 2012, and 2018. It’s not that Brown has changed. It’s that Ohio has.

Ohio used to be a political microcosm of the country. Without fail, between 1964 and 2016, Ohio’s presidential pick was also the nation’s choice of president. The consistency inspired the phrase, “As Ohio goes, so goes the nation.”

In the early 2000s, the state’s population growth began lagging behind the rest of the country. Over time, Ohio became less educated, older, whiter—and, accordingly, redder. When Trump ran in 2016, his brash, America First persona appealed to Ohioans who felt they had been forgotten by elite politicians prioritizing globalism over their kitchen-table issues. In both 2016 and 2020, Trump won the state by more than 8 points. That trend has continued this cycle: As of 11:30 pm ET, Trump was nearly 12 points ahead of Democratic presidential nominee Kamala Harris in Ohio.

In the end, Brown’s legislative history and broad coalition of blue-collar devotees couldn’t propel him to a fourth term. In today’s Ohio, only Trump’s support mattered.

Florida’s six-week abortion ban will remain the law of the land, as an abortion rights constitutional amendment failed Tuesday night.

With 91 percent of the vote tallied as of 9:20 p.m., support for Florida’s Amendment 4 hovered around 57 percent, according to Associated Press projections—shy of the 60 percent threshold required to pass. The amendment would have protected the right to an abortion until fetal viability, or until about 24 weeks’ gestation, and after viability if a medical provider determined that the procedure is necessary to preserve a patient’s health.

The amendment’s failure isn’t just a loss to the political momentum following the Dobbs v. Jackson Women’s Health Organization decision in 2022; it’s a major win for Republican Gov. Ron DeSantis, who wielded the power of his office to defeat the measure. “A bipartisan group of voters today sent a clear message to the Florida legislature,” a representative from Floridians Protecting Freedom, the campaign behind the amendment, said in a Tuesday night livestream. That message to lawmakers? “End the ban.”

DeSantis proclaimed victory within minutes of the final polls closing at 8 p.m. “Amendment 4 has failed,” he wrote in a post on X. More than a million more Floridians voted for Amendment 4 than voted for DeSantis in 2022.

Abortion rights supporters spent more in Florida—over $75 million—than in any other state with similar measures on the ballot. Despite popular support for abortion rights in the state, the ballot measure faced an uphill battle to victory, in more ways than one.

Most obviously, it needed to garner 60 percent support—more than the simple majorities that were needed to pass abortion protections in red states like Ohio, Kansas, and Kentucky. But DeSantis’ administration also challenged the measure in unprecedented ways, including by threatening television stations that ran pro-amendment advertisements, releasing a massive report weeks before the election accusing Floridians Protecting Freedom of “widespread election fraud,” and using a state agency website as a virtual billboard to oppose the amendment.

Since coming into effect in May, Florida’s six-week abortion ban has upended access to the procedure across the South. Tennessee, Alabama, Arkansas, Mississippi, and Kentucky all have near-total abortion bans, and Georgia and South Carolina have six-week bans. The number of abortions in Florida plummeted by 30 percent in the first two months of the ban, according to the Guttmacher Institute.

Amendment 4’s defeat marks the first failure of a state abortion rights amendment since Dobbs. Voters in seven states have passed abortion protections, and voters in nine other states have similar measures on their ballots.

In the lead-up to the 2020 presidential election, GOP consultants were fighting over strategy: Would going all-in on anti-trans messaging deliver then-President Donald Trump the suburbs in his race against former Vice President Joe Biden? Or should his campaign stay away from the issue, given widespread support among the electorate for LGBTQ rights like same-sex marriage? “This might become a hot cultural issue, but it’s not a thing yet,” one Republican consultant told Politico in the summer of 2020. “Right now, it’s just an easy issue for the other side to attack us on. They will call us bigots.”

So much has changed, as a network of conservative and religious-right groups coordinated to push hundreds of bills to wipe out trans youth health care, bar them from sports teams that match their gender identity, and censor discussion of LGBTQ issues in schools. With more than 129 anti-LGBTQ laws passed across the country in the last two years, GOP candidates now are betting that they’ve seeded enough anti-trans sentiment among voters to use transphobia as a motivating issue. It doesn’t seem to matter to Republicans that trans issues still tend to rank last among voters’ priorities: From August through early October, GOP candidates dropped $65 million on anti-trans advertising, according to a New York Times analysis. The hateful rhetoric has been deployed all the way down the ballot, in Senate races, statehouse contests, and state constitutional amendment campaigns.

Now, as the presidential race draws to a close, Trump’s campaign has made anti-trans ads the biggest focal point of its spending. The TV spots and social media posts spread falsehoods about medical care for trans youth, cast trans athletes as predators, and link support for trans people with support for (nonexistent) “partial-birth abortions.” Sports fans will recognize the constant refrain—“Kamala is for they/them. President Trump is for you.”—from game-day commercial breaks.

None of this bodes well for trans rights under either Trump or Harris, no matter what happens on Election Day, or in the weeks afterward. “​​I’ve been calling this the most anti-LGBTQ election since 2004,” says Sean Meloy, vice president of political programs at the LGBTQ+ Victory Fund, which works to elect queer and trans candidates. In 2004, George W. Bush used same-sex marriage as a wedge issue in his reelection campaign, betting it would drive conservatives to the polls. (As it turns out, right-wing voters were motivated by other priorities.) “They’re doing exactly the same thing now,” Meloy says. “Gay and lesbian people are understood and represented, and now they’re trying to dehumanize and use trans people and their experiences to get votes.”

Trump has pledged to defund gender-affirming care—and to ban it for minors.

Just being exposed to hateful political rhetoric can harm trans youth. Last year, in a Trevor Project survey, 86 percent of trans and nonbinary youth said debates about anti-trans bills negatively affected their mental health; half said they experienced cyberbullying; and a third didn’t feel safe going to the doctor. And when states pass anti-trans laws, the consequences for mental health are devastating: A study published in Nature Human Behavior in June found suicide attempts by trans youth ages 13 to 17 rose by as much as 72 percent a year after anti-trans laws were enacted.

Such laws are now the norm in Republican-dominated states. “In either scenario in November, we’re still facing that reality, where transgender people’s and also LGBTQ people’s rights more broadly depend almost entirely on what state they happen to live in,” says Logan Casey, director of policy research for the Movement Advancement Project. Already, trans people and their families are facing a “really difficult choice,” he says. “Stay in the place that they call home, seek healthcare somewhere else, or move out of state for potentially safer environments.”

If Trump wins the presidency, Casey says, the attacks succeeding now on the state level can be expected to graduate to the federal government. In his first term, Trump already provided a model for targeting transgender people. He banned them from the military; permitted anti-trans discrimination in health care; rolled back protections for trans students; and created a broad license for businesses to discriminate based on “religious objections”—often against LGBTQ people. More clues for a second term come from Project 2025, much of which was written by former Trump administration members, which equates “transgender ideology” with pornography and declares that it should be banned. The blueprint for a second Trump administration proposes wiping the terms “sexual orientation” and “gender identity” completely out of all federal policy.

And if the GOP wins both Congress and the White House, Trump has pledged to go further than before—cutting off federal funding for gender-affirming medical care and making it illegal nationwide for doctors to provide such care to minors.

But even without Congress, Trump would still have immense power to target transgender people through executive agencies. First on the list: reinterpreting federal laws in ways that eliminate protections for transgender people. That includes the Affordable Care Act, as well as Title IX, which forbids sex discrimination in education. Are schools and doctors expected to treat people according to their gender identity? The Obama and Biden administrations said yes. But in the years between, Trump appointees reversed those rules. “What they mean in terms of bathrooms, what they mean in terms of sports, what those regulations look like is very dependent on, is [Betsy] DeVos in charge or not?” says Jess Braverman, legal director at Gender Justice. 

Legal and policy experts who specialize in LGBTQ rights also warn that Trump appointees could create broad religious exemptions to federal nondiscrimination rules. One potential consequence: Government contracts going to organizations that exclude queer and trans people or insist on misgendering them. For example, during the first Trump administration, Catholic Charities was the only organization in Texas contracted to provide foster care placements for refugee children. The organization disqualified a lesbian couple, allegedly because they did not “mirror the Holy Family.” (Lambda Legal sued, and won.) Jennifer Pizer, Lambda Legal’s chief legal officer, says she’s particularly concerned about federal agencies giving contractors free rein, because the people they serve are often in dire need. “Whether it’s providing shelter or food or disaster relief, when they discriminate, then the people who are entitled to receive services, they don’t necessarily stay,” she explains.

The Project 2025–obsessed loyalists and ideologues who will staff a second Trump administration will not only set a tone for the massive federal workforce—one likely to be hostile to LGBTQ employees—but they’ll also be in charge of deciding how federal program money is distributed. “That money can go to responsible, community-based organizations and professional institutions that provide services consistent with professional standards, in a nondiscriminatory way,” Pizer says, “or to expand the religious infrastructure that we have in this country.”

“No matter which way the regulations go, no matter what they say, there’s always going to be litigation.”

Pretty much any agency moves are guaranteed to wind up in the courts, where lawsuits are already raging over trans-inclusive interpretations of Title IX and the ACA. Even when the Supreme Court weighs in—as it did in 2020 when it ruled that Title VII, the federal law banning sex discrimination in employment, protected transgender workers—the underlying issues aren’t put to rest. “No matter which way the regulations go, no matter what they say, there’s always going to be litigation,” Braverman says.

So it matters immensely who’s on the bench—another presidential power. During Trump’s first term, he appointed nearly 200 judges, reshaping the federal judiciary all the way up to the Supreme Court. As a result, those justices didn’t just overturn Roe v. Wade, they widened religious exemptions to civil rights law in ways that let more business owners refuse to serve LGBTQ clients. And, with all the recent state laws targeting transgender youth, a profusion of litigation over trans issues is making its way through the federal court system. In the most prominent case, United States v. Skrmetti, the DOJ has teamed up with trans families and has asked the court to decide if states can ban puberty blockers and hormone therapy for trans youth while permitting the same treatments for cisgender patients.

Oral argument for Skrmetti is scheduled for December—meaning the case should be submitted before the next president takes office. Pizer notes that it remains to be seen whether a Trump White House would try to reverse the DOJ’s current position on the case, and whether the justices would allow it.

In some ways, the backsliding in support for trans people is bipartisan. Democratic candidates this cycle have often appeared tentative or afraid of how conservative messaging about trans issues has already shaped public opinion. 

Some Democrats have adopted anti-trans rhetoric defensively, referring to trans people not by their gender identity but by the sex they were assigned at birth. “Let me be clear, I don’t want boys playing girls’ sports,” said Democratic Senate candidate Texas Rep. Colin Allred, running against Ted Cruz in Texas, in his response to a right-wing attack ad. Some LGBTQ-rights advocates chalked Allred’s response up to “messy” allyship; others called it a “dog whistle.” Either way, anti-trans activists were thrilled: “Beautiful Ted gets a major W here,” American Principles Project president Terry Schilling posted.

Even Kamala Harris, who dedicated an entire interview to describing her support for trans people during her first run for president in 2019, and who otherwise has a strong record advocating for the queer community, has stopped short of giving a robust defense of trans rights in her campaign. When attacked for allowing incarcerated people to access gender-affirming care, she shot back that such care was offered in federal prisons under the Trump administration. Gender-affirming care “is a decision that doctors will make in terms of what is medically necessary,” Harris elaborated under further questioning by NBC anchor Hallie Jackson. 

“It feels like that’s a long way from ‘we see you and we love you,’ which was your message to trans Americans in May,” Jackson pushed back. “What do you want the LGBTQ+ community to know as they’re looking for a full-throated backing from you for trans Americans?”

“I believe that all people should be treated with dignity and respect, period, and should not be vilified for who they are, and should not be bullied for who they are,” Harris replied. 

To some queer and trans observers, Harris’ general rebuttal about a need for inclusion is a disappointment, failing to meet the intensity of the anti-trans backlash. Others see it as an appropriate calculation for a dangerous political moment. “There are attacks against multiple groups of people, and so a counter-message that says, ‘Targeting people is not good, we need to come together as a country, we need to be inclusive as a country’—that is an apt message for these times,” Pizer says.

The stakes of the rhetoric are extremely high. While the average American’s opinions about transgender policies—from bathroom bans to gender-affirming care restrictions—are largely unformed and in flux, according to research from the University of Minnesota, politicians’ anti-trans messages have broadened support for restrictive policies. “As public opinion continues to evolve in this area,” the researchers concluded, “much will depend on the behavior and framing offered by elites.”

And the anti-trans rhetoric from Trump and his allies has already had a profound impact on queer people—none more so than the trans women and drag queens featured in the ads without their consent. “I haven’t been able to sleep,” Gabrielle Ludwig, a trans woman whose college basketball career was exploited in multiple ads, told The Hill. “I don’t want my family affected. I have granddaughters, daughters who are in college. I only did this because I love to play basketball. That’s all it ever was.”

With so much ultimately being up to the courts—and political battles sure to continue in the states, if not the federal government—Braverman believes a Harris win could be a chance to change the narrative. “The demonization and the discussion and the ‘let’s just debate people’s humanity’—that is the thing that is really making life hard for people,” they say.

Harris cannot unilaterally reverse the tide of anti-trans legislation in states; beyond her ability to affect policy areas like health and education, her greatest power lies in her words. “Laws and regulations are really important,” Braverman says, but “there needs to be more. There needs to be education, there needs to be understanding. There needs to be support from people in power.”

J. Ann Selzer has earned several nicknames throughout her 37-year-long stint leading the Des Moines Register’s Iowa Poll. She’s called the “Outlier Queen” when she breaks from what appears to be the consensus of political polls. And when her final pre-election polls paint a complicated picture for otherwise favored candidates, political insiders refer to her as the “Harbinger of Doom.”

Now, as the Election Day countdown timer inches toward zero, Selzer’s latest polling may be the specter that has worried some Republicans—the rageful spirit of Iowa women who lost abortion access this past summer. Contrary to every other poll, this poll of 808 likely Iowa voters shows that Kamala Harris has a 3-point lead over Donald Trump in one of the reddest red states. It’s within the poll’s margin of error but a far cry from Selzer’s previous tallies: In September, Trump enjoyed a 4-point lead over Harris, and in June, he was 18 points ahead of President Joe Biden.

“Nobody in their right mind would predict it,” Selzer said on the self-described “Never Trump” podcast The Bulwark. “Our methodology is to make no assumptions, and we made no assumptions.”

“Nobody in their right mind would predict it. Our methodology is to make no assumptions, and we made no assumptions.”

Selzer has gone against the polling consensus before—and has been proven right. She was one of the few pollsters who predicted Trump’s significant lead over Hillary Clinton in 2016, and she broke from the crowd in 2008 when her poll predicted Barack Obama’s 2008 win in the Iowa Democratic caucuses. The driving force behind the latest shift? Selzer says it’s women—particularly older and independent women—incensed by the Iowa Supreme Court’s decision to allow a six-week abortion ban to go into effect. 

The state Supreme Court’s June decision overruling a lower court’s block on the six-week ban may have come as a surprise, considering previous court decisions. In 2018, four years before the Dobbs v. Jackson Women’s Health Organization decision overturned Roe v. Wade, the Iowa court upheld the fundamental right to abortion, striking down a 72-hour waiting period and dooming the six-week ban, which was then the most restrictive abortion law in the United States. 

But this past summer’s opinion wasn’t a fluke; as I reported in July, it was the desired result of a yearslong scheme to rig Iowa’s courts against abortion. The GOP, which holds every statewide office and controls both legislative chambers, used its unencumbered power to overhaul the judicial selection process, giving Republican Gov. Kim Reynolds majority control over the committee that nominates justices. Her conservative appointees changed the makeup of the court. When lawmakers passed another six-week ban last year, the justices delivered on the Republican promise to restrict abortion—despite Iowans repeatedly signaling their support for abortion rights. The shift of a significant number of Iowa voters toward supporting Harris represents more than just anguish at the fall of abortion rights; it’s a strong rebuke to the GOP for its manipulation of the court.

The court’s opinion has likely produced what Selzer called a “jaw-dropping” result: Women age 65 and older, a typically Republican group, favor Harris over Trump 63 percent to 28 percent. Women overall favor Harris by 20 points, while Trump has a 4-point lead among men. “You need to win with women more than you lose with men,” Selzer said, “and we’re seeing that in these data.”

For his part, Trump dismissed the poll as “heavily skewed.” But Iowa House Democratic Leader Jennifer Konfrst says the results reflect what Democrats have been seeing on the ground. “They are sick and tired of politicians interfering in their doctor’s offices and are looking for people up and down the ballot who are going to actually fight for their freedoms,” Konfrst told the Des Moines Register. “And this issue is salient and real, and the fact that Vice President Harris all the way down to candidates for the Iowa House are talking about the same rights and freedoms shows that this is what Iowans are looking for.”

Earlier this month, Louisiana became the first state in the country to classify the two most common drugs used in medication abortions, mifepristone and misoprostol, as Schedule IV controlled substances, creating stiff penalties for their unauthorized use. Medical providers sounded alarms when the GOP-controlled legislature passed the law: Abortion is already banned in the state in nearly all cases, and the new classification would delay lifesaving care for people experiencing miscarriages and health conditions unrelated to pregnancy. 

Now, in a just-filed lawsuit, doulas, medical providers, and women denied care under the state’s abortion law argue that the new classification of mifepristone and misoprostol runs afoul of Louisiana’s constitution. By separating the drugs from others with similar risk profiles, the suit contends, the new law discriminates against people on the basis of their physical conditions, ones that are treated with mifepristone and misoprostol.

In Louisiana, controlled substances fall into five categories depending on their medical indications and risk for abuse—Schedule I being the highest risk, and Schedule V the lowest risk. The current list of Schedule IV drugs includes opioids, barbiturates, and benzodiazepines, all drugs with high potential for addiction. The classification of mifepristone and misoprostol as dangerous drugs subjects them to tight regulations. But they’re not dangerous drugs, nor do they have abuse potential like their Schedule IV counterparts; more than 100 studies have shown them to be safe and effective in ending pregnancy. Contrary to their current classification in Louisiana as having addictive potential, the Food and Drug Administration—which approved the drugs decades ago—has never found the medications to lead to physical or psychological dependence. 

Misoprostol and mifepristone have proven to be effective in a variety of contexts. Both are used in miscarriage care, mifepristone is used to treat ovarian cancer, and misoprostol is crucial to managing postpartum hemorrhages. Under Louisiana’s law, anyone in possession of either drug—except for pregnant women—is subject to five years in prison and a $5,000 fine. 

The classification, the lawsuit argues, subjects the drugs to a “highly regulated legal scheme” that delays care. Previously, misoprostol was commonly stored in obstetric hemorrhage carts or in staff’s pockets. But under its new status, only a provider licensed to administer controlled substances can retrieve the drug from locked cabinets where other scheduled substances, like narcotics, are stored. As a New Orleans OB-GYN told my colleague Julianne McShane, in a medical emergency, time is of the essence, and even a delay of several minutes can have disastrous consequences.

Pregnant women were already being denied care before the medications were reclassified. One of the plaintiffs, Kaitlyn Joshua, was denied miscarriage care by two hospitals because of the state’s abortion ban. “Now lawmakers have passed yet another law making it harder to get care during a miscarriage, and they did it without following the requirements of the State’s constitution,” Joshua said in a news release.

Earlier this month, Louisiana became the first state in the country to classify the two most common drugs used in medication abortions, mifepristone and misoprostol, as Schedule IV controlled substances, creating stiff penalties for their unauthorized use. Medical providers sounded alarms when the GOP-controlled legislature passed the law: Abortion is already banned in the state in nearly all cases, and the new classification would delay lifesaving care for people experiencing miscarriages and health conditions unrelated to pregnancy. 

Now, in a just-filed lawsuit, doulas, medical providers, and women denied care under the state’s abortion law argue that the new classification of mifepristone and misoprostol runs afoul of Louisiana’s constitution. By separating the drugs from others with similar risk profiles, the suit contends, the new law discriminates against people on the basis of their physical conditions, ones that are treated with mifepristone and misoprostol.

In Louisiana, controlled substances fall into five categories depending on their medical indications and risk for abuse—Schedule I being the highest risk, and Schedule V the lowest risk. The current list of Schedule IV drugs includes opioids, barbiturates, and benzodiazepines, all drugs with high potential for addiction. The classification of mifepristone and misoprostol as dangerous drugs subjects them to tight regulations. But they’re not dangerous drugs, nor do they have abuse potential like their Schedule IV counterparts; more than 100 studies have shown them to be safe and effective in ending pregnancy. Contrary to their current classification in Louisiana as having addictive potential, the Food and Drug Administration—which approved the drugs decades ago—has never found the medications to lead to physical or psychological dependence. 

Misoprostol and mifepristone have proven to be effective in a variety of contexts. Both are used in miscarriage care, mifepristone is used to treat ovarian cancer, and misoprostol is crucial to managing postpartum hemorrhages. Under Louisiana’s law, anyone in possession of either drug—except for pregnant women—is subject to five years in prison and a $5,000 fine. 

The classification, the lawsuit argues, subjects the drugs to a “highly regulated legal scheme” that delays care. Previously, misoprostol was commonly stored in obstetric hemorrhage carts or in staff’s pockets. But under its new status, only a provider licensed to administer controlled substances can retrieve the drug from locked cabinets where other scheduled substances, like narcotics, are stored. As a New Orleans OB-GYN told my colleague Julianne McShane, in a medical emergency, time is of the essence, and even a delay of several minutes can have disastrous consequences.

Pregnant women were already being denied care before the medications were reclassified. One of the plaintiffs, Kaitlyn Joshua, was denied miscarriage care by two hospitals because of the state’s abortion ban. “Now lawmakers have passed yet another law making it harder to get care during a miscarriage, and they did it without following the requirements of the State’s constitution,” Joshua said in a news release.

Two years after the US Supreme Court ended the federal right to abortion, tens of millions of Americans will go to the polls this November hoping to protect access to the procedure—whether their lawmakers like it or not. Ten states— some already with robust protections, others with near-total bans—have measures on their ballots to enshrine abortion rights in their constitutions. The expected outpouring of voters, including in key swing states, could help determine control of the White House, Congress, state legislatures, and state supreme courts.

Reproductive freedom has proved to be one of the strongest currents shaping the outcome of American elections since 2022. So far, voters in seven states have reacted to the end of Roe v. Wade by passing ballot measures aimed at restoring, and even expanding, Roe’s protections. In a few of those states, the voter-initiative process empowered the public to bypass GOP-dominated legislatures and supersede decades-old restrictions. Reproductive rights organizers are hoping to continue that winning streak on November 5. 

But faced with the broad appeal of abortion initiatives in GOP-led states such as Ohio, Republican officials have gone to sometimes extreme lengths to undermine the latest measures. In Florida, for example, Gov. Ron DeSantis has waged a multifront war on Amendment 4, threatening television stations that air ads favoring the measure and issuing a 348-page report accusing the Floridians Protecting Freedom campaign of “widespread petition fraud.” 

While most of this year’s measures have a common objective—protecting reproductive access—they take very different approaches to reaching that goal. Here is a rundown of what’s on the November ballot, which we will update as election results become available. 

Arizona

In anticipation of the end of Roe, Arizona Republicans passed a 15-week abortion ban in early 2022. But they also left in place an 1864 statute that outlawed nearly all abortions and threatened providers with jail time—a “zombie” law that was moot as long as Roe was in effect. This past April, the Arizona Supreme Court revived that Civil-War era ban by a 4–2 vote. The GOP-controlled legislature quickly repealed the old law, but many Arizonans were outraged at what the court had done, and the campaign to put Proposition 139 on the November ballot exploded. Prop 139 would enshrine a fundamental right to abortion in the Arizona Constitution and prohibit the state from restricting or banning abortion until the point of fetal viability—about 24 weeks. Abortions would be allowed later in pregnancy to save the mother’s life or to protect her physical or mental health. The amendment would also protect anyone who helps another person obtain an abortion.

A coalition of reproductive rights groups certified more than 575,000 signatures this past summer—the most ever validated for a citizens initiative in the state’s history, supporters said. In a New York Times/Siena College poll in late September, Prop 139 was ahead among likely voters by a resounding 58 percent. If it passes, Prop 139 could be used to challenge almost 40 abortion laws on Arizona’s books, including the existing 15-week ban, a prohibition on telehealth abortions, and a parental consent requirement for teenagers.

Colorado

Long before the Dobbs decision, Colorado legislators passed numerous laws safeguarding access to abortion. But after Dobbs, reproductive health advocates in the state concluded that even the strongest statutes weren’t strong enough—Colorado needed to enshrine those protections in its constitution. The measure they put on the November ballot, Amendment 79, wouldn’t just establish a right to abortion; it would repeal a 40-year-old constitutional provision that prohibited the use of state dollars to fund abortion. Sponsored by a coalition called Coloradans for Protecting Reproductive Freedom, the measure needs 55 percent of votes to pass. 

Surrounded by states with bans or heavily restrictive laws, Colorado is a crucial abortion access point for the West. With no gestational limits, the state is also a haven for anyone seeking an abortion later in pregnancy, as it is home to one of four clinics in the US that offer third-trimester procedures. Repealing the ban on state funding would allow Colorado to use its state Medicaid dollars to pay for abortions, making the procedure more accessible for low-income patients.

Florida

Florida’s Amendment 4 would enshrine in the state’s constitution the freedom to seek an abortion before fetal viability, and after viability if a medical provider determines that the procedure is necessary to preserve a patient’s health.

Gov. DeSantis and his GOP administration have done everything they can to sabotage the amendment—including sending “election police” to the homes of people who signed the petitions.

If the measure passes, it would dramatically improve access to reproductive care in Florida, which since May has banned abortions after six weeks of pregnancy. Before that, the state permitted abortions up to 15 weeks, and before Dobbs, until 24 weeks. The impact of the Florida vote will be felt throughout the Southeast: Tennessee, Alabama, Arkansas, Mississippi, and Kentucky all have near-total abortion bans; Georgia and South Carolina have six-week bans, and North Carolina’s 12-week ban is made more burdensome by a 72-hour waiting period. 

The stakes for passage are high, and so are the barriers. Over the last several election cycles, Florida has turned out more conservative voters than liberal ones. While reproductive rights are popular across the political spectrum, the state has a 60 percent threshold to approve constitutional amendments; the other red states that have passed abortion-protective measures since Dobbs—Kansas, Kentucky, Ohio—only required simple majorities. Meanwhile, Gov. DeSantis and his GOP administration have done everything they can to sabotage the amendment—including sending “election police” to the homes of people who signed the petitions, ostensibly to root out fraud. If the measure passes, DeSantis and his allies are widely expected to fight just as hard to overturn the results.

Maryland

Maryland’s Question 1, which was placed on the November ballot by the state legislature, does not mention “abortion”—much to the chagrin of supporters and opponents alike. Instead, the amendment broadly establishes the constitutional right to “reproductive freedom,” including the freedom to decide whether to continue or end a pregnancy. It needs a simple majority to pass.

Maryland already has some of the least restrictive abortion laws in the country: There is no gestational limit, state Medicaid covers the procedure, and a shield law protects patients who travel from states with abortion bans. This has made the state a critical access point for abortion seekers further along in pregnancy, as well as people traveling from the South. Abortion protections are widely popular in the state; in a recent poll by the University of Maryland, Baltimore County, 69 percent of respondents said they plan to vote for Question 1.

Missouri

Missouri’s near-total abortion ban took effect mere minutes after the Supreme Court overturned Roe v. Wade in 2022—making it the first state in the nation to broadly prohibit abortion. Abortion-rights advocates soon set about crafting a ballot initiative to end the ban, inspired by wins in other states. Now, with Amendment 3, voters will decide whether they want the right to “reproductive freedom”—defined as the ability to make and carry out one’s own decisions about contraception, abortion, and healthcare during pregnancy. If approved by a simple majority, the amendment would set up a legal battle to overturn the current ban and challenge the many other Missouri laws that regulated abortion providers nearly out of existence even when Roe was still in effect.

Amendment 3’s proponents, a coalition known as Missourians for Constitutional Freedom, have traveled a rocky road just to get the measure before voters. They’ve overcome blatant obstruction by top state GOP officials, multiple legal challenges, and deep internal divisions over whether the initiative should allow the state to ban abortions after fetal viability. The final text protects abortion rights until viability, and permits later abortions if needed to protect the life or health of the pregnant person.

Montana

Constitutional Initiative 128 establishes the right to make and carry out decisions about one’s own pregnancy, including abortion. If passed, it would allow the state to regulate abortion after fetal viability, so long as those restrictions don’t prevent abortions that health care providers deem medically necessary. The amendment, which requires more than 50 percent of the vote, would also prevent the government from criminalizing patients and anyone who helps a person exercise her abortion rights.

If top Republican state officials had it their way, the measure would not even be on the ballot. State courts intervened at multiple points; the Montana Supreme Court overruled Attorney General Austin Knudsen’s initial rejection of the proposed amendment, nixed Knudsen’s drafted ballot language saying the amendment “may increase the number of taxpayer-funded abortions,” and threatened Secretary of State Christi Jacobsen with a contempt charge because she refused to hand over the sample ballot petition to the campaign behind the amendment, Montanans Securing Reproductive Rights. After abortion rights supporters submitted nearly double the required 60,000 signatures, Jacobsen even tried changing the rules to throw out the signatures of inactive registered voters, until a district court ordered her to stop.

Thanks to the state supreme court, abortion is currently legal in Montana until fetal viability, despite the best efforts of Republican state legislators to restrict access. Montanans have already brushed off one GOP attempt to stigmatize abortion; in November 2022, 52 percent of voters rejected a legislature-initiated statute that would have made it a felony for doctors to not provide care to infants born alive after induced labor, a cesarean section or an “attempted abortion.” (The law wasn’t necessary since Montana, like every other state, already makes infanticide a crime.)

Nebraska

Nebraska voters will see dueling abortion amendments on their November ballots. Initiative 434 restricts abortion rights, banning the procedure after 12 weeks of pregnancy with limited exceptions. That’s essentially the same law already on the state’s books—but the measure would enshrine it as a constitutional amendment, making it much harder to repeal. And because the amendment doesn’t protect abortion before the 12-week mark, state politicians could always go further and pass a complete ban, as Republican Gov. Jim Pillen has pledged to do.

By contrast, Initiative 439 expands abortion rights, creating a “fundamental right to abortion until fetal viability, or when needed to protect the life or health of the pregnant patient.” In practice, the amendment would roughly double the length of time for pregnant people in Nebraska to get an abortion. Crucially, it would block lawmakers from passing a total ban.

If the double initiatives sound confusing, well, that’s the point. Anti-abortion activists have repeatedly tried to muddy the waters about which ballot initiative is which, as Rachel Cohen at Vox has reported. They’ve also tried to get the pro-abortion initiative thrown off the ballot on a technicality, but the Nebraska Supreme Court shot them down.

Given the confusion, it is possible that both measures could pass. In that case, the one with the most votes wins.

Nevada

Nevada, one of the swingiest states in the 2024 election, has its own version of the Equal Rights Amendment, passed by voters in 2022. But it didn’t explicitly mention protections for abortion. Question 6 constitutionally enshrines the right to abortion until fetal viability or for the health or life of the mother, as determined on a case-by-case basis by health care providers. Any pre-viability restrictions must be directly related to promoting the health of the pregnant person and “consistent with accepted clinical standards of practice.” This year’s vote is just the first step in a multiyear process; assuming a simple majority of voters approve it, the measure must be passed again in 2026 to become part of the constitution.

Thanks to a law passed in 1973, abortion has been legal in Nevada until 24 weeks. Because voters passed a referendum on that law in 1990, it can only be changed by a direct ballot measure. Protections for abortion are very popular in Nevada; a University of Maryland poll conducted over the summer found that about 70 percent of state voters oppose criminalizing abortion at any stage of pregnancy. The campaign behind the amendment, Nevadans for Reproductive Freedom, has raised nearly $10 million since January, according to campaign finance reports; the Coalition for Parents and Children PAC, which successfully sued to block an initial version of the amendment that covered reproductive healthcare more broadly, hasn’t raised or spent any money.

New York

New York’s Proposal 1 may not include the word “abortion,” but it would create first-in-the-nation protections for the rights of pregnant people.

The proposal is a broad version of the Equal Rights Amendment, the long-running feminist effort to guarantee women’s rights in state and federal constitutions. Right now, New York’s constitution only forbids government discrimination on the basis of race and religion. Prop 1 adds more protected categories to that list: disability, age, ethnicity, national origin, and sex, including sexual orientation, gender identity, and gender expression. Those types of discrimination are already banned under state law, but by enshrining protections in the constitution, Prop 1 would make them harder for legislators to attack in the future—for example, if New York politics keep trending rightward.

Here’s where abortion comes in: The amendment also bans discrimination based on “pregnancy status, pregnancy outcomes, and reproductive health care and autonomy.” Not only does that definition go farther than any other state, it leaves little room for judges to interpret in ways that might limit abortion access, according to Katharine Bodde, of the New York Civil Liberties Union.

Yet while New York Democrats initially viewed Prop 1 as a surefire way to boost voter turnout, their right-wing opponents have seized on transphobic messaging to great effect—making this blue-state fight unexpectedly close.

South Dakota

South Dakota’s current abortion ban is one of the most extreme in the country, with all abortions banned except when needed to save a pregnant person’s life. Amendment G, backed by a group called Dakotans for Health, would replace that law with a trimester-based system allowing increasing restrictions on abortion as a pregnancy progresses.  

In the first trimester, the state would be banned from interfering with “a woman’s abortion decision and its effectuation.” In the second trimester, the state could restrict abortion in ways “reasonably related to the physical health of the pregnant woman.” Third-trimester abortions could be banned, except when necessary to preserve a pregnant person’s life or health. The amendment needs a simple majority to pass.

Planned Parenthood and other abortion-rights groups aren’t supporting Amendment G, which they’ve said doesn’t go far enough. But the conservative Republicans who dominate state politics are still so terrified of the measure that they passed an emergency law to let voters revoke their petition signatures—then opponents of the measure led a phone banking effort to dupe signers into pulling their support. Why are state Republicans spooked? “If you can do it in South Dakota, it will strike fear into the hearts of every red-state legislature in the country,” Dakotans for Health co-founder Adam Weiland told the American Prospect.

Madison Pauly, Abby Vesoulis, Julianne McShane, and Nina Martin contributed reporting. This is a developing story. Check back for updates.

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Top image photo credits: Octavio Jones/AFP/Getty; RJ Sangosti/The Denver Post/Getty; William Campbell/Getty; Rachel Aston/Las Vegas Review-Journal/Getty; Getty(3)

Every Monday morning, the staff of the Abortion Fund of Ohio’s intake line starts fresh, answering calls, following up on voicemails, and doling out cash to people who can’t afford to go to their abortion appointments. The team of three fields as many financial requests as they can until the money allotted for the week runs out. Lately, that’s been by Tuesday. Sometimes they can stretch the funds until Wednesday.

The Ohio Fund, one of the largest abortion funds in the United States, didn’t always operate this way. When I first spoke with the fund in August 2023, it didn’t even have monthly caps on the amount of money it gave callers. Back then, even though the wave of “rage donations” that followed the end of Roe v. Wade had receded, there was still enough money to pay for patients’ medical costs, travel, and child care.

But as costs of care—and daily life—have risen, so, too, has demand for the fund’s services. Ohio’s relatively new constitutional protections for abortion—the result of a ballot measure approved last year—have made it a destination for needy patients from nearby states where onerous restrictions remain in place. When national abortion rights organizations suddenly announced this summer that they would be slashing the amount of money they devote to defraying patients’ medical costs, the financial problems escalated. 

To put all this in perspective: In July 2023, the Ohio Fund spent about $100,000 helping 300 or so people get abortions. This past July, they fulfilled twice as many requests for help with half as much money—and the number of calls has continued to rise. People who might once have been able to pay for their own abortions are now begging for assistance, and people who always would have needed financial assistance are begging for more. 

“The first word that comes to my mind is helpless,” says Taren Holliman, the Ohio Fund’s program manager. “It feels very helpless when you are not able to fully bridge the gap, or help bridge the gap, in a way that actually allows a person to access the health care that they deserve.”

It’s not just the Ohio Fund that is struggling to meet callers’ needs. Every abortion fund I spoke with, from the East Coast to the Great Plains to the Deep South, is in varying stages of crisis, with many taking unprecedented measures to ward off looming disaster. As the abortion issue dominates the 2024 elections, from Kamala Harris’ campaign to the battle for the Senate to ballot measures in a record 10 states, the frontline groups that have taken on the lion’s share of the post-Dobbs burden—the clinics that provide abortions, and the funds that get people to their appointments—are barely able to keep their doors open and phones on the hook.

“What I’m seeing looks like the collapse of the abortion care system.”

Just days after the state’s voter-approved constitutional amendment officially took effect in December 2023, the Ohio Fund closed shop until February due to a lack of money. That was despite a record-breaking year for the fund, during which it almost doubled the money it doled out, to $1.5 million, and nearly quadrupled the number of abortion seekers it helped. 

As Ohio’s courts begin implementing the ballot measure, the financial strains are likely to grow. With its six-week ban permanently struck down, and its 24-hour waiting period and restrictions on medication abortion temporarily blocked, the state is poised to become an even more vital access point for abortion patients from neighboring states with near-total bans, including Kentucky, West Virginia, and Indiana.

Ohio’s abortion-rights measure has been a model for many of the ones on the ballot. But the nationwide lack of abortion funding infrastructure presents a stark reminder of the post-November reality, even if Harris wins: Protecting the right to abortion is very different from ensuring that patients, particularly low-income ones, can access abortion care. Draconian laws, stigma, and a lack of buy-in from large donors and local and state governments have produced a funding catastrophe that has been decades in the making—and is unlikely to be solved anytime soon. Dr. Diane Horvath, director of an independent abortion clinic in Maryland, a state with robust abortion laws and an abortion-rights amendment on the November ballot, put it bluntly: “What I’m seeing looks like the collapse of the abortion care system.”

For low-income women in particular, access to abortion has long depended on the benevolence of donors. For nearly 50 years, the Hyde Amendment has prohibited federal funds from going toward abortions except when a woman’s life is threatened or in cases involving rape or incest. Many states implemented their own versions of Hyde, barring state Medicaid funds from being used for abortions; some states also passed laws banning private insurers from covering abortions in their states.

Despite the promises of Roe, abortion remained far from accessible—and unnecessary regulations on abortion providers and mandatory waiting periods that delayed care only exacerbated the access problem. Grassroots funds, mostly funded by small, individual donations, cropped up in communities across the country to offer financial assistance and, crucially, stigma-free emotional support to people seeking abortion care. 

In 1993, an alliance of 22 local organizations in 14 states established the National Network of Abortion Funds to better connect abortion seekers to help and advocate for abortion rights. Now made up of almost 100 funds, the network gave out more than $18 million in grants last year, tax filings show. The fall of Roe produced a swell of “rage donations” to national organizations and local funds alike, enabling some funds to expand their staff, service areas, and funding amounts. But those donations have since dried up.

For years, and especially since Dobbs, local abortion funds and the people they serve have relied on two big national organizations to help defray the medical costs of procedures for patients who meet financial eligibility requirements: Planned Parenthood and the National Abortion Federation. Planned Parenthood funds abortions at its own clinics, and NAF funds abortions at NAF-member independent clinics. 

Local abortion funds fill in the gaps, helping pay for things like plane fares, motels, and babysitters; many, like the Ohio Fund, do not have income limits or other eligibility requirements that cut some pregnant people off from national assistance. Although NAF has a limited fund for non-appointment expenses like travel and child care, the overwhelming burden of practical support falls on the shoulders of local organizations. 

Immediately after the US Supreme Court overturned the federal right to abortion, NAF and Planned Parenthood committed to funding up to half of patient medical costs, and NAF offered additional assistance to patients in emergencies. Before the Dobbs decision, NAF spent, on average, $50,000 a month to defray abortion costs, president and CEO Brittany Fonteno says. In the two years after Dobbs, it spent $6 million a month. 

But this past July 1, NAF cut its abortion funding in half; going forward, it would only cover 30 percent of qualifying patients’ appointment costs. Fonteno says the decision was difficult but necessary to ensure the organization’s future. “Our funding has not been able to keep pace with the need,” Fonteno tells me. “We were set to run out of funds by fall if we had continued to fund at the pace that we were funding at previously.”

Planned Parenthood, meanwhile, joined a campaign called Abortion Access Now that aims to pass federal abortion protections in the next decade. On the two-year anniversary of the Dobbs decision, the campaign launched with $100 million from national groups including the ACLU, National Women’s Law Center, and the Center for Reproductive Rights. A week later, Planned Parenthood’s patient appointment funding cuts, which mirror NAF’s, went into effect. Planned Parenthood did not provide comment by publication time.

“It is disheartening to be engaged in this work and, in moments of political crisis, to witness groups that should be our partners in the fight—uplifting, investing in, and centering our expertise and critical role—fail us, too.”

Local organizations like the Ohio Fund felt the impact immediately; they were inundated with more patients needing more money, even as their own donations were drying up. “It actually feels repulsive to offer someone $200 who has a $1,500 appointment cost and says that they can’t afford to eat or pay their rent,” says Lexis Dotson-Dufault, the Ohio Fund’s executive director. “What do we do? Because if we cover your whole appointment cost, that’s our budget for the day.”

And big institutional donors, like foundations, haven’t stepped in to help. Dotson-Dufault pointed out to me that when large donors decide to fund reproductive rights, they usually pour their money into national organizations. Planned Parenthood, for instance, which has over $330 million in net assets (despite losing nearly $68 million last year), received a $275 million donation in 2022 from billionaire MacKenzie Scott, the ex-wife of Amazon founder Jeff Bezos, to increase abortion access nationwide.

More than 30 local abortion funds went public with their frustrations in an open letter published in August in The Nation. “Abortion funds exist because governmental and political systems have failed our communities—primarily Black, Indigenous and Native, immigrant, rural, and low-income—and abandoned us in times of need,” the letter reads. “It is disheartening to be engaged in this work and, in moments of political crisis, to witness groups that should be our partners in the fight—uplifting, investing in, and centering our expertise and critical role—fail us, too.”

The leaders behind national groups counter that local abortion funds are partly to blame for the low cash flow. An anonymous organization leader working on abortion ballot campaigns in multiple states told Vox in September that local funds’ visions for the future—for example, making abortion (and all health care) free and eliminating parental consent laws—alienate more mainstream would-be donors. “If you’re only communicating in very extreme messaging about abortion access, you’re not broadening your base of donors, you’re just talking to the 12 people who already agree with you,” the anonymous source said. “A lot of people who would love to donate to funds and probably don’t understand the need are turned off before they even get in the door by the language and behavior.”

Dotson-Dufault offers a different perspective. She attributes the lack of institutional funding to deeply rooted stigma around abortions, which large donors share and are continuing to perpetuate. “I think a lot of people want to say that they’re supporting abortion,” she tells me, “but not go as far as paying for the abortion itself.”

The thing about abortion is that it is inherently time-sensitive. And with each week that passes, the procedure gets significantly more expensive.

In Ohio, the cheapest option—medication abortion—costs about $650, and it’s only available until 12 weeks’ gestation. Costs for an in-clinic procedure, which is legal until 22 weeks, range from $735 to over $1,600, depending on how far along the pregnancy is. Just delaying care for a week—for example, to secure money from an abortion fund—raises the cost by several hundred dollars. That’s because patients having later-term abortions require more complex care; what can be completed in one appointment in the first trimester requires multiple days and pricey anesthesia in the second or third trimester. 

And for nearly all people whose pregnancies are beyond the point of viability, getting an abortion requires travel and a lot of time. There are just four clinics in the US that offer third-trimester abortions, and three of them are in the DC metropolitan area. The Brigid Alliance, which helps cover travel costs for patients beyond 15 weeks’ gestation, spends an average of $2,300 per client on non-medical expenses. Between plane tickets, childcare and multiple-day hotel stays,  the costs for some clients can approach $10,000, says The Brigid Alliance’s Sarah Moeller. That’s on top of costs for the procedure itself, which can exceed $15,000 in the third trimester.

Abortion patients have always relied on local funds to fill the funding gap, especially low-wage patients who can’t afford to take time off from work, much less pay for travel and child care. But those gaps are increasingly urgent—and nearly insurmountable. “Something that’s become more common is people are coming to us with these gaps the day before or the day of their appointment,” says Alisha Dingus, development director at the DC Abortion Fund. Patients are calling the fund needing as much as $10,000, sometimes from inside the clinic waiting room. In the months after Dobbs, such last-minute requests were something the DC Fund, one of the most well-resourced local funds in the country, used to be able to cover without a second thought. Not anymore. 

Now, it’s not unusual for the DC Fund to put out emergency requests for donations on social media. It’s not a policy change that came lightly; the DC team had decided against such callouts before. “We don’t want to create this sense of panic across our community, because we are such a critical fund,” Dingus says. “The other funds say, ‘Oh, if DCAF is in trouble, then what’s going to happen to callers who need care after 28 weeks?’”

We have two callers with appointments on Tuesday with a $8,300 gap. We are calling on this community to dig deep & show up to close this gap. We have seen y’all do it before & we hope you can again We keep us safe! https://t.co/IWBAHrRgG3

— DC Abortion Fund (@DCAbortionFund) August 29, 2024

The answer, increasingly, is that the independent providers who offer the costliest and least accessible abortion care are operating at a loss so as not to turn patients away. Even in states like Maryland, which has no gestational limits on abortion, Planned Parenthood does not offer third-trimester abortions. So later-pregnancy abortion care falls to a handful of independent clinics, many of which don’t have years of savings to dip into when patients come in crisis. 

The DuPont Clinic in DC, for example, spent about $100,000 to offset patients’ funding gaps in the first two months after the NAF cuts, Karishma Oza, the clinic’s care coordination director, says. DuPont is often a clinic of last resort; by the time someone ends up there, they’ve likely been turned away from other providers that can’t afford to subsidize their medical care. “Every week, our case management team has to reassure patients to come to their appointments despite not having all their funding together,” Oza tells me.

“We are in a position where, if things don’t change, if we’re not able to find alternative sources of funding, then we will have to close.”

It’s a similar situation at Partners in Abortion Care, a clinic in Maryland that provides abortions up to 34 weeks’ gestation. Since opening after Dobbs, Dr. Diane Horvath, its medical director and co-founder, says the clinic has always helped cover medical costs for patients. But since NAF slashed direct patient subsidies, women are coming in with significantly greater funding gaps. Partners in Abortion Care, like many independent clinics, relies on block grants from NAF to offer emergency financial help. With its own grant cut in half, the clinic now shoulders the bulk of patient medical costs.

“We’re operating at a loss,” Horvath told me in September. She and the clinic staff want to give people the care they need, “but we are in a position where, if things don’t change, if we’re not able to find alternative sources of funding, then we will have to close.”

Even in states with strong abortion protections, abortion providers and funds don’t often receive local or state government support. Horvath’s clinic receives no grant from Maryland, for instance. Many abortion funds told me they rely on small donations from community members for the bulk of their money supply. As costs rise, and demand for funds’ help alongside it, small donations aren’t enough.

Faced with increased need and a declining cushion of cash, the DuPont Clinic in DC has formed The Lavender Fund to beef up its emergency reserve of money for patients who can’t afford their appointments. Meanwhile, many funds, like Ohio’s, have implemented monthly or weekly funding caps or have slashed limits already in place. It’s not just money funds are worried about; they are trying to balance a drastic rise in demand with their workers’ and volunteers’ emotional wellbeing. 

Many of the people who volunteer or work at abortion funds—especially those who staff call lines—have themselves had abortions. The Ohio Fund’s Holliman, for instance, became involved in reproductive justice after facing barriers to her own abortion care while in college. It’s not just passion that drives the people who operate local abortion funds; it’s the intimate knowledge of everything that impedes care, from appointment fees to confusion about laws to a lack of support—and what it means if a fund cannot make up a person’s outstanding cost.

“You’re literally looking at a crossroads of two completely different futures in front of you,” Holliman says. “As much as I hate to say it, there are going to be people who are not able to access the care that they need.”

When the US Department of Health and Human Services finalized a rule in May asserting that gender dysphoria can be considered a disability under federal anti-discrimination laws, it codified what the overwhelming majority of courts have found for nearly a decade. The new rule put states on notice: Discrimination against transgender people in employment, education, health care, child care, housing, and elsewhere may violate federal disability protections, and the Biden administration was prepared to fight it.

Now, in a lawsuit led by Texas Attorney General Ken Paxton, 17 states are asking a federal court to strike down the rule in its entirety, including numerous provisions that have nothing to do with trans people. This isn’t a random collection of states; 15 of them have passed restrictions on gender-affirming care, and all have embraced myriad anti-trans policies. 

Among the states’ objections to the new federal rule: They would have to “expend time, money, and resources” to accommodate employees with gender dysphoria, including using the pronouns that align with their identities, eliminating sex-specific dress codes, and letting employees use gender-aligned bathrooms or locker rooms. Nebraska’s attorney general is concerned that his state’s restrictions on gender care put it at risk of disability rights complaints and federal investigations. South Dakota objects to the rule “essentially add[ing] a new category of potentially disabled individuals” whose gender care must be covered by Medicaid.

But gender dysphoria is just part of the 130-page federal rule. It also protects disabled parents’ rights in child welfare cases and prevents hospitals from using disability as a factor in determining who gets care in crisis situations, such as equipment shortages during a pandemic. It adds Long Covid to the list of conditions that may constitute a disability and strengthens protections against unnecessary institutionalization, requiring that care be offered in the least restrictive setting and, ideally, in a patient’s community. 

“The attack is really about the regulatory process of the federal government, and this will impact almost every interaction that a disabled person has with the services and supports that they receive.”

Striking down the entire rule would have wide-reaching implications for all disabled Americans and other marginalized groups who rely on federal agencies’ interpretations of decades-old laws to enforce their rights, says Mia Ives-Rublee, senior director of the Center for American Progress’ Disability Justice Initiative. “They’re utilizing LGBTQ issues as a wedge,” Ives-Rublee says. “The attack is really about the regulatory process of the federal government, and this will impact almost every interaction that a disabled person has with the services and supports that they receive.”

The new rule pertains to two federal statutes passed decades ago to protect people with disabilities on multiple fronts. The Rehabilitation Act of 1973 prohibits discrimination on the basis of disability by the federal government, federal contractors, and—in its Section 504—by any organizations or employers that receive federal funds. The Americans with Disabilities Act (ADA), signed into law in 1990, broadened disability protections into most aspects of public life, including education, access to businesses open to the public, and public transportation. Both statutes define a disability as “a physical or mental impairment” that “substantially limits” one or more major life activities. 

When the Rehabilitation Act and ADA were passed, gender dysphoria was not a recognized medical condition, and both statutes expressly excluded “transvestism, transsexualism,” and “gender identity disorders not resulting from physical impairments” from the definition of disability. But over the decades, medical experts and courts have come to understand that for many people who identify with a gender different from the one assigned to them at birth, there can be profound psychological distress and other major negative effects in their work and social lives. In 2013, gender dysphoria was added to the Diagnostic and Statistical Manual of Mental Disorders.

Since then, lawsuits by individuals—the primary way the ADA is enforced—have forged a body of legal decisions that recognize gender dysphoria as a protected health condition and its exclusion from disability protections as discriminatory, says Ben Klein, senior director of litigation and HIV law at GLBTQ Legal Advocates and Defenders. The exclusion of gender dysphoria “was based on obvious animus toward a disfavored group. That is a concept that judges who look at petitions have easily understood—the bias is so clear,” Klein says. 

The 4th Circuit Court of Appeals broke legal ground in 2022 when it became the first federal appeals court to rule on the issue of whether gender dysphoria could be considered a disability under federal disability protection statutes. The court determined that the basis of a gender dysphoria diagnosis—whether it causes a noticeably negative impact on daily life—distinguishes it from the ADA’s definition of gender identity disorder. (The US Supreme Court declined to hear the case in June 2023, letting the decision stand.) Lower federal courts have found, similar to the 4th Circuit, that gender dysphoria is distinct from gender identity disorder. Others have found that even if gender dysphoria is a gender identity disorder, it results from a physical impairment: a mismatch between a person’s physical body and gender identity that can be remedied through gender care. 

In finalizing its new rule—the first administrative update to Section 504 in half a century—the Department of Health and Human Services alluded to this body of case law, which it said has “shifted the legal landscape of disability discrimination protections.” But none of that matters much to the states that joined the Texas lawsuit, which was filed with little national media attention in late September. 

The lawsuit seizes upon the original exclusionary language in the ADA, claiming that what the medical community now considers gender dysphoria falls under the law’s concept of gender identity disorder. “The Biden Administration is once again abusing executive action to sidestep federal law and force unscientific, unfounded gender ideology onto the public,” Paxton said in a press release announcing the suit. “Texas is suing because HHS has no authority to unilaterally rewrite statutory definitions and classify ‘gender dysphoria’ as a disability.”

Beyond the gender dysphoria issue, the lawsuit also makes broad claims about “new regulatory burdens” and “substantial costs” associated with the rule’s impacts to state Medicaid programs. Alaska, Montana, and Nebraska, for instance, argue that the rule’s “least restrictive setting” requirement will be difficult to implement because of health care worker shortages and their states’ unique geographies. 

“One of the goals of the ADA is to address discrimination and stereotypes, particularly about stigmatized health conditions. Gender dysphoria is the quintessential stigmatized health condition.”

Klein and Ives-Rublee emphasized that both the Rehabilitation Act and ADA were written vaguely with the intent that, over the years, experts working for federal agencies would reexamine and refine the regulations implementing the statutes, as scientific and public understanding of disability evolves. When the ADA was passed, trans identity was pathologized, Klein says. “One of the goals of the ADA is to address discrimination and myths and stereotypes, particularly about stigmatized health conditions,” he tells me. “Gender dysphoria is the quintessential stigmatized health condition.”

The new Texas case is just one of many avenues GOP officials are using to enforce their anti-trans beliefs. As I’ve reported, Republican attorneys general—many from the same states as in the Paxton lawsuit—are also threatening major medical associations with criminal investigations for promoting trans youths’ access to gender care.

Ives-Rublee warns that the Texas suit is also part of a multifaceted attack on the power of federal agencies to interpret civil rights laws, including protections for pregnant workers and access to reproductive health care. This broad conservative effort to rip the teeth out of the administrative state was emboldened by a series of Supreme Court decisions last term, including one that ended courts’ expected deference to federal agency interpretations of vague laws. 

Because the gender dysphoria lawsuit was filed in the federal district court in Lubbock, Texas, any appeal will go to the 5th Circuit Court of Appeals, home to some of the most radically conservative decisions in recent legal history. If the 5th Circuit sides with the states in this case, it would create a conflict with the 4th Circuit decision that could force the Supreme Court, with its far-right supermajority, to weigh in. “I am almost 100 percent sure this is their intention,” Ives-Rublee says.

The day after the assassination attempt on former President Donald Trump in July, Pastor Diane Mullins took the microphone in front of the southwest Ohio church she and her husband, Jim, preside over and began to pace in front of a large LED screen with the graphic of a billowing American flag.

“I’m tired of holding back because I’m running for a stupid office, and I don’t care if they hear that,” she said, her voice slowly rising. “The only reason I’m running, it’s about the kingdom of God and his righteousness that should rule and reign in the government of the United States of America.” Her cadence quickened, the electric organ and audience’s applause swelling to meet her fever pitch as her words turned into commands. “It is time for the godly, it is time for the anointed of God to arise! Awake! Arise! Advance! Be the church. Stop being afraid!”

From the city of Hamilton, population 63,000, the urban center of a mostly rural county, Mullins is running a statehouse campaign in which she presents herself as a mainstream Ohio Republican, running to defend “conservative values.” But when she appears before her hundreds of congregants, Mullins has been much more explicit about the interdependence of faith and politics. “The principle of separation of church and state is a lie,” she said in a 2021 sermon. “The Constitution of the United States was written by men who were Christian men, who were principled men, because they were concerned that one day, the government would try to take over the church and the Christians.”

A Christian nationalist gospel that might have once been a fringe of the Republican Party now commands a central role, from Speaker of the House Mike Johnson to down-ballot races across the country—to school boards and local government. Should they be elected, their mission is to infuse government with the word of God. 

“It’s this belief that while the United States might have different people, different races and ethnicities or religions, it was built by white Anglo-Protestants,” says Andrew Whitehead, co-director of the Association of Religion Data Archives at Indiana University, Indianapolis. “And those folks today who are white Anglo-Protestants really have the clearest heritage to help run this country, to have a say in what it should look like.”

“From three to four years old, if you would say, ‘What do you wanna be when you grow up,’ I would tell you I was gonna work for Jesus.”

The child of devout Christians, Mullins always felt certain of her destiny. “From three to four years old, if you would say, ‘What do you wanna be when you grow up,’ I would tell you I was gonna work for Jesus,” Mullins said on the Christian radio show Shaped by Faith, in 2018. But she figured her vocation was to support a ministering husband, in much the same way her mother did for her father, Pearl Robinson, a Pentecostal pastor in the Cincinnati suburb of Hamilton, where Mullins lives today.

For years, Mullins was Jim’s supportive spouse, when he took over what was then called the Calvary Christian Center in Hamilton from his parents. But over three consecutive nights in 2015, Mullins says, messages from God interrupted her sleep. On day one, he said, “Awake. Arise. Advance.” On the second, he said, “Honeybee.” And on the third, “Deborah.”

A biblical figure who was Israel’s first female judge and prophet, Deborah, or “Honeybee” in Hebrew, appears in the Book of Judges and guided an Israeli warrior to lead 10,000 soldiers to defeat an army of Canaanites (people who lived in what is now Syria, Lebanon, Jordan, Israel, and Palestine). In the “Song of Deborah,” she is commanded by God to “awake” and “arise” as a “mother in Israel.” For Mullins, these divine messages and the spectacle of what she described as “the nasty women’s march” after Trump was elected in 2016, convinced her to start a ministry called Deborah’s Voice. Aspiring to be “the voice of Christian women,” the ministry’s priorities include “ending abortion,” “protecting traditional marriage,” and “supporting Christian women in politics.” Starting in 2018, Deborah’s Voice even held rallies across the country. “We just feel that women have a voice in this nation, and we don’t want the wrong voice,” Mullins told the Christian Post ahead of the ministry’s 2018 rally in Washington, which was attended by a few hundred people. 

Devoted Christian nationalists tend to be comfortable with the idea of authoritarian social control, Whitehead tells me. The logic goes that chaotic circumstances require rigid rules, and strong leaders like Trump to enforce them, to restore the order that people crave. Mullins views America’s founding documents as sacred and needing protection from change. Meanwhile, the devil—via the so-called “deep state”—has been working internally to thwart God’s plans. 

“It’s this belief that while the United States might have different people, different races and ethnicities or religions, it was built by white Anglo-Protestants.”

The story of Deborah has often appeared in Mullins’ sermons over the years, especially to underscore the significance of a female prophet who was not only trusted but revered. “She was where I believe the church is today,” Mullins preached in September. “We are a righteous people in between the established church and the world, the culture that we live in, that is so ungodly and unrighteous.” Within this context, Mullins says, around November 2023, God once more directed her, this time to campaign for office and serve him in the Ohio House of Representatives as a representative from the solidly red 47th District. Running for office wasn’t her decision, she says, it was God’s. His timing was propitious: November 2023 was when Ohioans voted to legalize recreational cannabis and constitutionally protect abortion. “Everything is about the kingdom,” Mullins said in a January sermon. “So, what is it about the kingdom that God wants to use me for in that?” Mullins’ campaign did not respond to Mother Jones’ interview requests or questions.

This was not Mullins’ first statehouse campaign. Four years ago, before Ohio enacted new legislative maps, she unsuccessfully challenged a different Republican incumbent, telling southwest Ohio newspaper the Journal-News that she was a pro-gun, anti-abortion candidate who wouldn’t compromise her “conservative core beliefs.” What is new, however, is the amount of dark money that she has received, which helped her—like the biblical David—defeat the political Goliath in the primary against three-term incumbent Rep. Sara Carruthers. Make Liberty Win, a Virginia-based hybrid PAC/super-PAC that seeks to elect “liberty-defending” state lawmakers, poured more than $96,000 into supporting Mullins (and opposing Carruthers), $40,000 more than Mullins’ own campaign spent.

By February, the race got ugly, culminating in Carruthers filing a complaint against Make Liberty Win with the Ohio Elections Commission for mailing attack ads without disclosing it was the source. The ads claimed Carruthers “threw a single mother out of her house,” referring to a complicated story in which the surrogate of Carruthers’ two children filed a breach of contract suit against the candidate. Carruthers settled the lawsuit out of court in 2022 and the case is now sealed. (Mullins told the Journal-News in February that “I would never OK a mailer like that.”)

Make Liberty Win spent more than $1.8 million in about a dozen GOP primaries in Ohio, mostly to oppose Republican incumbents, part of the so-called “Blue 22,” in favor of more MAGA-minded candidates unwilling to compromise with Democrats. Eight of the 12 challenged Blue 22 Republicans held onto their seats. But the challengers who did win, like Mullins, presented themselves as being much more hardline conservatives, each highlighting their devotion to Christian values. Ty Mathews, for example, running to represent Ohio House District 83, has three pillars guiding his campaign: God, country, and family. “There’s a reason why [God] is number one,” Mathews explains in a video on his campaign website.

The inflexibility and radical nature of their respective candidacies seem to ignore the fact that Ohioans, including Republican voters, have rejected the state GOP’s efforts to stifle more progressive policies, says Paul Beck, a professor emeritus of political science at Ohio State University. “There’s an old adage in politics that power corrupts, and absolute power corrupts absolutely,” he tells me. “We’re seeing that with these Republican supermajorities. Many of their members now think they can really do anything.”

“Everything is about the kingdom. So, what is it about the kingdom that God wants to use me for in that?”

Mullins hasn’t publicly campaigned much since securing the Republican nomination, trading stump speeches and meet-and-greets for private fundraising events and occasional appearances at county fairs and holiday parades. She doesn’t have a campaign website or a WinRed fundraising page. And aside from references to supporting the Second Amendment and opposing abortion, her policy platform is scant. On her candidate Facebook page, she blends patriotic posts with praise and prayers for Trump, and images of her hobnobbing with Donald Trump Jr. and the GOP’s US Senate candidate in Ohio, Bernie Moreno.

Despite her proclivity for conspiracy theories, Mullins has been relatively mum on immigration—which is striking given the national spectacle Trump and his vice presidential hopeful Ohio Sen. JD Vance have created with disproven claims about Haitian immigrants eating pets. Springfield is about an hour north of Mullins’ district, and Trump and Vance’s falsehoods have, as Republican Gov. Mike DeWine put it, made the community the “epicenter of vitriol over America’s immigration policy.”

Mullins’ political base of operations appears to be inside Calvary Church, a medium-sized brick building adorned with a large cross and a looming white steeple. Every Sunday, worshippers gather in a large auditorium, led by a live contemporary rock band and a chorus of singers. Pastors encourage the unsaved in the audience to make themselves known and receive God. Calvary Church weaves nondenominational teachings with elements of Mullins’ Pentecostal upbringing; she speaks in tongues, for instance, and congregants line up for some faith healing from her and her husband.

For years, Mullins has warned people in her church of the impending end times, pointing to evidence that seemed to be everywhere: Satan “pervert[ed] what male and female was all about” in society. The culture’s ungodliness ushered in the spread of the “man-made” coronavirus. The Antichrist has infiltrated American institutions through communism. From her pulpit, she emphasizes this church’s unique role in bringing the unsaved into the Lord’s “harvest” before Jesus’ return, casting out the ever-present “enemy,” and aligning the United States with the Holy Word. 

One Sunday morning this past summer, less than 5 miles down the road from Calvary Church, Mullins’ Democratic opponent, Rev. Vanessa Cummings, was preaching at Payne Chapel AME Church. As Cummings finished delivering her sermon to the dozen or so people in the pews, she emphasized the need to pray for unity, world peace, and healing from divisiveness. She’s been a pastor at this 184-year-old Black church for three years and has ministered across the state. A longtime public servant and community activist, she served as vice mayor and city councilmember of nearby Oxford and is the vice president of Oxford’s NAACP chapter. She has long helped with voter registration and education drives. Today, I am the only white person in the room and I am reminded of the Reverend Martin Luther King Jr.’s famous observation that 11 a.m. on Sunday was the “most segregated hour of America.”

Sitting across from me in her office after the service, Cummings acknowledges that in a district that is nearly 62 percent Republican, the odds are stacked against her. But, she notes, “If I didn’t think I could win, I wouldn’t run.” The voters she’s spoken to on the campaign trail are desperately seeking change, Cummings tells me, and they’re tired of politicians making decisions against their constituents’ wishes because of their personal beliefs. 

While her faith guides her in her personal life, she emphatically rejects the tenets of Christian nationalism that Mullins preaches. “She believes there’s no separation of church and state. I believe there is a separation of church and state,” Cummings says. “She believes this is a stupid position. I believe it’s a position we should fight for, to get to serve the people.”

“It’s good I’m not God, I’d kill ‘em, every one.”

A few hours earlier, as I sat in a back pew as hundreds of people filtered into Mullins’ Calvary Church, a countdown timer inched toward zero on the three LED screens on the wall behind the pulpit. With a couple of months before the election, Mullins’ sermon was far less political than many of the ones I’ve watched on the Calvary Church YouTube channel. Her message was simple: God does not care what sins you have committed in your past, as long as you believe that Jesus Christ is your savior and you devote yourself to living in line with God’s word.

As forcefully as she has condemned the “perversion” and “unrighteousness” in society, in this sermon she emphasized this church would welcome, with open arms, a homeless drug addict or “two men who come in holding hands” who hope to hear the Lord’s good news. Similarly, people struggling with sins like “abortion, unforgiveness toward an abuser, fornication, sex before marriage” and “pornography” should not be afraid to accept Jesus into their hearts. It’s Mullins’ twist on the common refrain “Love the sinner, hate the sin.” 

It can be hard to reconcile that message with the image of the devilish “enemy” she regularly evokes. And it is the proliferation of sin, she preaches, that prevents the full realization of God’s visions for the world. “There’s too much darkness, too much deep state, too much sexual sin, too much abuse,” Mullins said in 2020. “And every day, I go: Oh Lord, Jesus. And he says, ‘I’m just letting you see it, I’ve known it all along.’ You know what my next thought is? It’s good I’m not God, I’d kill ‘em, every one…We need God. Thank God we’re not him, because we’d probably all be dead, too.”

Last August, the American Academy of Pediatrics renewed its guidance supporting the use of puberty blockers, hormone therapy, and other medical care for transgender children and teens. At a time when trans issues have moved to the center of the culture wars, the AAP—the main medical association representing US pediatricians, with 67,000 members—said its action was aimed at supporting trans minors amid new waves of anti-trans laws.

Now, Republican officials from 21 states have accused the medical group of violating state consumer protection laws by supporting gender-affirming care for trans youth. More ominously, they’re demanding that the AAP turn over extensive records about how it developed its policy. 

In a letter signed by Idaho Attorney General Raúl Labrador and sent to the medical group this week, the GOP officials claim that the AAP is misleading parents and the public about the reversibility of puberty blockers and hormone therapy. The letter calls gender-affirming care “medical experimentation” and demands the AAP produce years’ worth of communications and documents related to its guidance for treating trans youth.

“It is without question that anti-transgender policies, and the dangerous rhetoric surrounding them, take a measurable toll on the health and safety of transgender and nonbinary young people all across the country.”

The letter was signed by the usual array of Republican suspects, including the top lawyers of Texas, Ohio, Florida, and nearly every state with laws restricting gender-affirming care. As state bans face legal challenges and injunctions, these attorneys general appear to be laying the groundwork for a new strategy to further their ideological agendas over the objections of medical experts.

The AAP is the leading US authority on pediatric health care, regularly releasing policy statements on a slew of topics, including medical treatment of LGBTQ youth. Last year, in addition to reaffirming its 2018 guidance on gender-affirming care, the AAP board of directors also authorized a systematic review of existing research to develop an “expanded set of guidance” for pediatricians. The 2018 policy statement supports a “collaborative, multidisciplinary approach” to treating gender dysphoria in trans youth that includes the ongoing, informed consent of the child and parents. 

The GOP officials’ latest salvo disregards the AAP’s expertise and presents a bad-faith interpretation of the association’s gender-care policy. “Children with gender dysphoria need and deserve love, support, and medical care rooted in biological reality,” Labrador asserted in a statement announcing the letter. “Parents should be able to trust that a doctor’s medical guidance isn’t just the latest talking point from a dangerous and discredited activist agenda.”

Labrador’s letter leans heavily on a dispute over whether puberty blockers are reversible, citing the UK-commissioned Cass Review, issued this past April, which experts have criticized for its methodology and biased assertions about gender identity. “Telling parents and children that puberty blockers are ‘reversible’ at the very least conveys assurance that no permanent harm or change will occur,” the letter reads. “But that claim cannot be made in the face of the unstudied and ‘novel’ use of puberty blockers to treat gender dysphoria.” 

In fact, AAP itself emphasizes that there are risks associated with the use of puberty blockers to treat gender dysphoria—mostly the potential for distress caused by social stigma. Research on long-term effects is limited and varied, with some studies suggesting impacts on bone density and fertility. As the Mayo Clinic points out, bone density concerns are typically addressed with calcium and vitamin D supplements. Meanwhile, organizations including AAP and the World Professional Association for Transgender Health (WPATH) recommend that before initiating treatments, providers and patients extensively discuss the fertility implications and options. Indeed, the gap in long-term research on gender-affirming care is precisely why AAP and other experts advocate for the continued study of evidence-based practices.

The Republican officials gave the AAP until October 8 to hand over all its communications with WPATH related to standards of care, dating back to 2020; all communications with the White House regarding gender-affirming care, and “substantiation” for many aspects of the AAP’s 2018 guidance. That policy statement already includes nearly 100 citations, including systematic reviews, AAP committee findings, and other organizations’ standards of care.

The AAP did not respond to Mother Jones’ request for comment.

Twenty-six states have passed laws restricting gender-affirming care for trans youth, according to the health policy think tank KFF. In Idaho—where Labrador is the top law enforcement official—medical providers face felony charges and up to 10 years in prison for prescribing puberty blockers and hormone therapy to trans minors. Most state bans, including Idaho’s, are facing legal challenges, but so far, only Arkansas’ law has been permanently blocked. (Florida’s ban, which also restricts care for trans adults, is in effect while the state appeals.) The US Supreme Court will hear a case this term regarding the constitutionality of Tennessee’s ban on the use of puberty blockers and hormones in trans youth. 

Meanwhile, the effect of laws targeting transgender youth and adults is becoming increasingly evident. A new study by researchers from The Trevor Project, published in the journal Nature Human Behavior, suggests a causal link between anti-trans laws and suicide attempts in trans people. The study of 61,000 transgender and nonbinary kids and young adults, conducted from 2018 to 2022, found that attempted suicide among trans children increased by as much as 72 percent in states that passed restrictions on gender-affirming care.

“It is without question that anti-transgender policies, and the dangerous rhetoric surrounding them, take a measurable toll on the health and safety of transgender and nonbinary young people all across the country,” says Jaymes Black, CEO of The Trevor Project. “It’s not necessary to fully understand their experience to acknowledge that they—like all young people—deserve dignity, respect, and the ability to lead healthy and full lives.”

Last August, the American Academy of Pediatrics renewed its guidance supporting the use of puberty blockers, hormone therapy, and other medical care for transgender children and teens. At a time when trans issues have moved to the center of the culture wars, the AAP—the main medical association representing US pediatricians, with 67,000 members—said its action was aimed at supporting trans minors amid new waves of anti-trans laws.

Now, Republican officials from 21 states have accused the medical group of violating state consumer protection laws by supporting gender-affirming care for trans youth. More ominously, they’re demanding that the AAP turn over extensive records about how it developed its policy. 

In a letter signed by Idaho Attorney General Raúl Labrador and sent to the medical group this week, the GOP officials claim that the AAP is misleading parents and the public about the reversibility of puberty blockers and hormone therapy. The letter calls gender-affirming care “medical experimentation” and demands the AAP produce years’ worth of communications and documents related to its guidance for treating trans youth.

“It is without question that anti-transgender policies, and the dangerous rhetoric surrounding them, take a measurable toll on the health and safety of transgender and nonbinary young people all across the country.”

The letter was signed by the usual array of Republican suspects, including the top lawyers of Texas, Ohio, Florida, and nearly every state with laws restricting gender-affirming care. As state bans face legal challenges and injunctions, these attorneys general appear to be laying the groundwork for a new strategy to further their ideological agendas over the objections of medical experts.

The AAP is the leading US authority on pediatric health care, regularly releasing policy statements on a slew of topics, including medical treatment of LGBTQ youth. Last year, in addition to reaffirming its 2018 guidance on gender-affirming care, the AAP board of directors also authorized a systematic review of existing research to develop an “expanded set of guidance” for pediatricians. The 2018 policy statement supports a “collaborative, multidisciplinary approach” to treating gender dysphoria in trans youth that includes the ongoing, informed consent of the child and parents. 

The GOP officials’ latest salvo disregards the AAP’s expertise and presents a bad-faith interpretation of the association’s gender-care policy. “Children with gender dysphoria need and deserve love, support, and medical care rooted in biological reality,” Labrador asserted in a statement announcing the letter. “Parents should be able to trust that a doctor’s medical guidance isn’t just the latest talking point from a dangerous and discredited activist agenda.”

Labrador’s letter leans heavily on a dispute over whether puberty blockers are reversible, citing the UK-commissioned Cass Review, issued this past April, which experts have criticized for its methodology and biased assertions about gender identity. “Telling parents and children that puberty blockers are ‘reversible’ at the very least conveys assurance that no permanent harm or change will occur,” the letter reads. “But that claim cannot be made in the face of the unstudied and ‘novel’ use of puberty blockers to treat gender dysphoria.” 

In fact, AAP itself emphasizes that there are risks associated with the use of puberty blockers to treat gender dysphoria—mostly the potential for distress caused by social stigma. Research on long-term effects is limited and varied, with some studies suggesting impacts on bone density and fertility. As the Mayo Clinic points out, bone density concerns are typically addressed with calcium and vitamin D supplements. Meanwhile, organizations including AAP and the World Professional Association for Transgender Health (WPATH) recommend that before initiating treatments, providers and patients extensively discuss the fertility implications and options. Indeed, the gap in long-term research on gender-affirming care is precisely why AAP and other experts advocate for the continued study of evidence-based practices.

The Republican officials gave the AAP until October 8 to hand over all its communications with WPATH related to standards of care, dating back to 2020; all communications with the White House regarding gender-affirming care, and “substantiation” for many aspects of the AAP’s 2018 guidance. That policy statement already includes nearly 100 citations, including systematic reviews, AAP committee findings, and other organizations’ standards of care.

The AAP did not respond to Mother Jones’ request for comment.

Twenty-six states have passed laws restricting gender-affirming care for trans youth, according to the health policy think tank KFF. In Idaho—where Labrador is the top law enforcement official—medical providers face felony charges and up to 10 years in prison for prescribing puberty blockers and hormone therapy to trans minors. Most state bans, including Idaho’s, are facing legal challenges, but so far, only Arkansas’ law has been permanently blocked. (Florida’s ban, which also restricts care for trans adults, is in effect while the state appeals.) The US Supreme Court will hear a case this term regarding the constitutionality of Tennessee’s ban on the use of puberty blockers and hormones in trans youth. 

Meanwhile, the effect of laws targeting transgender youth and adults is becoming increasingly evident. A new study by researchers from The Trevor Project, published in the journal Nature Human Behavior, suggests a causal link between anti-trans laws and suicide attempts in trans people. The study of 61,000 transgender and nonbinary kids and young adults, conducted from 2018 to 2022, found that attempted suicide among trans children increased by as much as 72 percent in states that passed restrictions on gender-affirming care.

“It is without question that anti-transgender policies, and the dangerous rhetoric surrounding them, take a measurable toll on the health and safety of transgender and nonbinary young people all across the country,” says Jaymes Black, CEO of The Trevor Project. “It’s not necessary to fully understand their experience to acknowledge that they—like all young people—deserve dignity, respect, and the ability to lead healthy and full lives.”

Public resources in Springfield, Ohio, were strained long before former President Donald Trump’s baseless claims about Haitian immigrants eating their neighbors’ pets derailed the presidential debate. Now, after days of vile disinformation from Senator JD Vance and other prominent Republicans, dozens of bomb threats, an immigration town hall that attracted thousands, and the possibility of a Trump visit to town, local and state services have been stretched to their limits. Even as officials hope the major waves of national attention are behind them, they’re preparing for more of the same.

On Thursday, Springfield Mayor Rob Rue announced that he has signed an emergency proclamation granting himself the power to bypass the usual contract procurement and bidding procedures, letting him quickly enter into agreements with vendors related to “public safety concerns.” The proclamation—which originated with Rue’s office, not the city council—will remain in place until further notice, according to the Springfield News-Sun. Flanked by Republican Gov. Mike DeWine and regional and state officials, Rue told reporters that the emergency powers were a precaution that would also allow the city to recoup security costs from the state. “It is not an indication of immediate danger, but allows us to efficiently and effectively protect our public safety,” he said.

Dozens of buildings across Springfield—including schools, businesses, and city hall—have been targeted by bomb threats over the past week. Although every threat has turned out to be false, each has required significant time and resources—including federal bomb-detection dogs—to investigate. DeWine has deployed three dozen state police officers to conduct daily sweeps of every school building in the district; those officers will remain on hand, he says, until school officials call them off.

If Trump cancels his visit, “it would convey a significant message of peace to the city of Springfield concerning immigration.”

The national storm bearing down on the small western Ohio city has disrupted almost every aspect of daily life. Threats of violence have forced college classes online and city buildings to close. An annual cultural diversity festival was canceled. And while DeWine started off the news conference by focusing on how to address some of the impacts associated with the recent influx of 15,000 Haitian immigrants to the community—for example, adding another mobile health clinic and allocating millions of state dollars to increase the availability of vaccinations and primary medical care—it quickly devolved into a discussion about bomb threats and Trump.

Springfield’s mayor, who is a Republican, has been speaking out for months about how the surge in immigrants has strained schools, hospitals, and city resources. But on Thursday, Rue honed in on the toll that national attention has taken on the city’s public safety system. For example, later that day, former GOP presidential candidate Vivek Ramaswamy was planning to hold an immigration town hall that ultimately attracted thousands of would-be attendees, forcing the city to close off the street. Rue reiterated his hope that Trump, who has announced he will travel to Springfield in “the next two weeks,” will reconsider. “A visit from the former president will undoubtedly place additional demands on our safety infrastructure,” Rue said. “Should he choose to change his plans, it would convey a significant message of peace to the city of Springfield concerning immigration.”

Meanwhile, Rue and DeWine pointed to signs that life in Springfield is returning to normal. The stream of bomb threats has become a trickle. Children are returning to school in greater numbers each day. In not-so-subtle terms, DeWine told reporters that what Springfield needs most in its quest for normalcy is for the national media to go away.

“We will return, in the not too distant future, to a point where you all are going to be writing and talking about, reporting on the nightly news about something else,” DeWine said. “And as soon as that happens, I think you’re going to see the temperature go down.”

Public resources in Springfield, Ohio, were strained long before former President Donald Trump’s baseless claims about Haitian immigrants eating their neighbors’ pets derailed the presidential debate. Now, after days of vile disinformation from Senator JD Vance and other prominent Republicans, dozens of bomb threats, an immigration town hall that attracted thousands, and the possibility of a Trump visit to town, local and state services have been stretched to their limits. Even as officials hope the major waves of national attention are behind them, they’re preparing for more of the same.

On Thursday, Springfield Mayor Rob Rue announced that he has signed an emergency proclamation granting himself the power to bypass the usual contract procurement and bidding procedures, letting him quickly enter into agreements with vendors related to “public safety concerns.” The proclamation—which originated with Rue’s office, not the city council—will remain in place until further notice, according to the Springfield News-Sun. Flanked by Republican Gov. Mike DeWine and regional and state officials, Rue told reporters that the emergency powers were a precaution that would also allow the city to recoup security costs from the state. “It is not an indication of immediate danger, but allows us to efficiently and effectively protect our public safety,” he said.

Dozens of buildings across Springfield—including schools, businesses, and city hall—have been targeted by bomb threats over the past week. Although every threat has turned out to be false, each has required significant time and resources—including federal bomb-detection dogs—to investigate. DeWine has deployed three dozen state police officers to conduct daily sweeps of every school building in the district; those officers will remain on hand, he says, until school officials call them off.

If Trump cancels his visit, “it would convey a significant message of peace to the city of Springfield concerning immigration.”

The national storm bearing down on the small western Ohio city has disrupted almost every aspect of daily life. Threats of violence have forced college classes online and city buildings to close. An annual cultural diversity festival was canceled. And while DeWine started off the news conference by focusing on how to address some of the impacts associated with the recent influx of 15,000 Haitian immigrants to the community—for example, adding another mobile health clinic and allocating millions of state dollars to increase the availability of vaccinations and primary medical care—it quickly devolved into a discussion about bomb threats and Trump.

Springfield’s mayor, who is a Republican, has been speaking out for months about how the surge in immigrants has strained schools, hospitals, and city resources. But on Thursday, Rue honed in on the toll that national attention has taken on the city’s public safety system. For example, later that day, former GOP presidential candidate Vivek Ramaswamy was planning to hold an immigration town hall that ultimately attracted thousands of would-be attendees, forcing the city to close off the street. Rue reiterated his hope that Trump, who has announced he will travel to Springfield in “the next two weeks,” will reconsider. “A visit from the former president will undoubtedly place additional demands on our safety infrastructure,” Rue said. “Should he choose to change his plans, it would convey a significant message of peace to the city of Springfield concerning immigration.”

Meanwhile, Rue and DeWine pointed to signs that life in Springfield is returning to normal. The stream of bomb threats has become a trickle. Children are returning to school in greater numbers each day. In not-so-subtle terms, DeWine told reporters that what Springfield needs most in its quest for normalcy is for the national media to go away.

“We will return, in the not too distant future, to a point where you all are going to be writing and talking about, reporting on the nightly news about something else,” DeWine said. “And as soon as that happens, I think you’re going to see the temperature go down.”