Using International Human Rights to Address Anti-Transgender and Anti-Gender-Affirming Care Laws in the United States

Abstract

Over the past five years, the number of new United States laws banning gender-affirming care, restricting public access to services and spaces for transgender and gender-diverse persons, and forcibly outing transgender youth in schools has increased dramatically. Much of the focus in the media and research has been on the domestic political and social causes of these anti-transgender and anti-gender-affirming care laws and their devastating effects on vulnerable transgender and gender-diverse communities. This article argues that the current wave of anti-transgender and anti-gender-affirming care laws violates civil and human rights in the context of international human rights resolutions and principles on healthcare and displacement. I explore the implications of using international human rights to challenge anti-transgender and anti-gender-affirming care legislation and what coalitional possibilities exist when expanding the fight against these laws transnationally.

1. Introduction

In September 2023, the Canadian government’s Global Affairs office updated its travel advisory for LGBTQ+ Canadian citizens traveling to the United States, warning them about laws and policies enacted in several American states that could affect them negatively (Chasan 2023; Government of Canada 2023). Jérémie Bérubé, a spokesman for Global Affairs, clarified that the advisory came in response to recent U.S. laws banning drag shows and restricting transgender, transsexual, nonbinary, gender-diverse, and intersex (TGI) communities from accessing gender-affirming care, bathrooms and public spaces and participating in sporting events (Gillies 2023). The Canadian government’s LGBTQ+ travel advisory for the United States was covered in many international news outlets. Mélanie Joly, Canada’s minister of foreign affairs, said global governments should be “keeping an eye on America” and its anti-LGBTQ+ policies (Aoraha 2023).

This is not the first time that human rights abuses in the United States have drawn international attention. However, the Canadian LGBTQ+ travel advisory is notable in the context of increasing global attention on the abuses against LGBTQ+ communities within the United States. In January 2026, two former presidents of the International Association of Genocide Scholars warned that the United States is in the early stages of genocide against TGI communities based on its restrictive laws removing or restricting civil rights and rising eradication rhetoric against TGI American citizens from conservative populist and right-wing politicians and activists (Braghman 2026). In 2025, state and federal legislatures considered an unprecedented number of anti-TGI bills. The two preceding years also broke records for the number of anti-TGI bills considered. More than one thousand anti-TGI bills were introduced in U.S. state legislatures in 2025, most targeting restrictions on healthcare access and legal recognition of bathroom, sports, and education policies (Transgender Legislation Tracker 2026). Of these, one hundred and thirty-eight laws banned gender-affirming care for TGI youths and adults, while two hundred and fifteen laws introduced some form of restriction against TGI education. These include laws that force educators to out TGI students to their caretakers and forbid them to use students’ preferred pronouns, prohibit LGBTQ+-inclusive curriculum and ban TGI students from sports and bathrooms that correlate to their gender identity (Transgender Legislation Tracker 2026). As of December 2025, three hundred and seven anti-TGI laws had been passed. These laws deny access to fundamental healthcare as well as rights and protections to access public services and education. This number does not include President Trump’s string of executive orders, including Executive Order 14201, “Keeping Men Out of Women’s Sports,” and Executive Order 14168, “Defending Women from Gender Ideology Extremism.” These orders ban transgender athletes and criminalize gender-affirming care. The recent United States v. Skrmetti U.S. Supreme Court Case added further legal support for anti-TGI legislation restricting gender-affirming care for minors by agreeing with the lower court decision that courts can uphold laws restricting gender-affirming care for minors as long as the law is not officially based on sex, thereby surpassing the Fourteenth Amendment. While this does not ban gender-affirming care nationwide, it makes it exponentially harder to challenge restrictive anti-TGI laws in the courts (Huberfeld and Ulrich 2025).

The extreme increase in the number of laws being introduced and passed in the past five years to ban gender-affirming care in the United States is a manifestation of the growing worldwide movement against gender ideology. Gender ideology encompasses women’s and LGBTQ+ political, social, and legal activism (Paternotte and Kuhar 2017), as well as scholarship interrogating gendered differences and gender as a social construct (Takács et al. 2022). Topics of focus include legislation and institutional reforms regarding sexual and reproductive rights, same-gender marriage and adoption, transgender and gender-affirming care, and protection against systemic gender- and sexuality-based violence. Gender ideology has been framed as a threat to American values, “a sort of conspiracy aimed at seizing power and imposing deviant and minority values on ordinary people” (Paternotte and Kuhar 2017, p. 7) and, in turn, destroying fundamental power structures based on whiteness, class, heteronormativity, and cisnormativity.

Anti–gender ideology movements intersect with the rise of illiberalism, white nationalism, and populism, as politicians and political groups aim for centralization of the state and instrumentalize the state’s authority to determine the limits of gender expression, bodily autonomy, and personhood for citizens (Butler 2024). This contradicts U.S. civil rights legislation and several constitutional amendments and violates several international human rights resolutions. Similar restrictive and persecutory anti-TGI policies are emerging in Europe, Russia and Central Asia, the Middle East, South America, and Africa (ILGA Europe 2025; ILGA World 2025).

While the United States is seeing an unprecedented rise in anti-TGI legislation, it continues to position itself as an international leader of human rights; this is clearly contradictory. During his presidency, President Biden repeatedly stated his administration’s opposition to state laws banning gender-affirming care (Biden 2024) but was reticent to condemn anti-TGI legislation as a violation of international human rights. This is interesting since international human rights laws and resolutions are often included in U.S. statements decrying anti-LGBTQ+ laws abroad. For example, in December 2023, President Biden submitted an official statement condemning Uganda’s Anti-Homosexuality Act (AHA), which increases incarceration time for “promotion of homosexuality” and allows the death penalty for “aggravated homosexuality”:

On the 75th anniversary of the UN General Assembly’s adoption of the Universal Declaration of Human Rights, the United States joins people around the world in reiterating its call for the immediate repeal of the AHA and for the Ugandan government to respect the universal human rights of all people in Uganda.

(The White House 2023)

In the year President Biden made this statement, more than 500 anti-LGBTQ+ bills were introduced in U.S. state legislatures. The U.S. Department of Homeland Security recorded 2023 as a significant year for hate crimes and threats of violence against the LGBTQ+ community (Margolin and Grant 2023). The National Center for Transgender Equality (NCTE) warned that TGI deaths in the United States were rising with increased anti-TGI laws (NCTE 2023). Still, the Biden administration ideologically distanced the United States from Uganda’s AHA. One could present a counterargument that banning gender-affirming care is less severe than enforcing the death penalty, so the United States is not morally compelled to compare itself to Uganda. However, both cases involve violence rooted in political genderphobia and the mobilization of nationalism, illiberalism, and social-economic divides to scapegoat sexual and gender minorities. The banning of transgender healthcare, especially for marginalized TGI youths and adults, can lead to death, whether through societal violence and dehumanization or through extreme suffering, self-harm, and suicide (Barbee et al. 2022; Mann et al. 2024; Howell and Maguire 2023; Tordoff et al. 2022). Both forms of legislation directly control individuals’ bodies and the ability to live. Why, then, is Uganda’s AHA condemned as violating the Universal Declaration of Human Rights while U.S. anti-TGI laws are not?

Failing to connect the violence in both countries allows the United States not to hold itself accountable for contributing to the development of Uganda’s AHA. However, U.S.-based evangelical missionaries have promoted homophobia, transphobia, and misogyny to Uganda’s religious and political leaders (Seo 2017; Palecek and Tazlar 2021), while U.S. metal and mining corporations have caused economic instability. At the same time, the United States has provided decades of military assistance to prop up the undemocratic Museveni dictatorship.

Just two months before Biden’s statement on Uganda’s AHA, the United Nations Human Rights Council (UNHRC) reviewed U.S. compliance with the International Covenant on Civil and Political Rights (ICCPR). A UNHRC review panel questioned U.S. federal, state, and local officials on Indigenous rights, voting rights, freedom of expression, reproductive rights, criminal legal reform, immigrants’ rights, LGBTQ+ rights, and more. The concluding observations noted the lack of measures to incorporate the ICCPR in “good faith” at U.S. federal, state, local, and territorial levels. It called for the creation of an independent national human rights institution to hold perpetrators accountable for human rights violations. In addition to condemning racial profiling, anti-Black discrimination, and violence against women and Indigenous communities, the UNHRC drew particular attention to the increasing violence and discrimination against LGBTQ+ communities. Noting the increasing amount of anti-LGBTQ+ legislation at the state level, the UNHRC urged the United States to repeal state laws that discriminate based on sexual orientation and gender identity and adopt comprehensive legislation prohibiting discrimination on these grounds (United Nations 2023). In this context, invoking international covenants, resolutions, guidelines, and principles to condemn human rights violations of LGBTQ+ populations abroad is an example of the United States’ economic, political, and social hegemony over global issues. Critiques of the United States as an influential player in international human rights are valid, especially in the context of the ICCPR—one of the few international human rights covenants the United States has ratified and is legally obligated to implement. If the United States does not act in “good faith” to implement and uphold the ICCPR, the international community could theoretically step in and offer protection in its place. In this case, the international community would be obligated to supplement members’ human rights protection (Draper 2023).

The creation of international covenants, resolutions, guidelines, and principles regarding human rights is a critical step to institutionalizing human rights, but implementation and enforcement of them, especially in hegemonic economically, socially, and politically powerful countries, is increasingly apparent under the second Trump administration. In March 2025, UN human rights chief Voker Türk addressed the UNHRC over his deep concerns about shifting U.S. policies intended to dismantle anti-discrimination protections and gender equality (UN Rights Chief Laments ‘Shift in Direction’ in United States 2025). A month later, the UNHCR voted to renew the mandate of an LGBTQ+ expert in response to increasing anti-LGBTQ+ legislation in the United States and elsewhere (ILGA World 2025). While global concern over the increase in anti-LGBTQ+ rhetoric and policies in the United States is growing, the Trump administration also formally removed the United States from the World Health Organization (U.S. Department of Health and Human Services 2025), removed funding for the UNHRC and the UN Relief and Works Agency for Palestine Refugees in the Near East, and cut four billion dollars of aid for additional global health programs (The White House 2025; Faguy 2025).

Under the current circumstances, in which the U.S. government not only violates international human rights norms but also leverages its economic and geopolitical influence to pressure other states and international bodies to adopt parallel restrictive policies and language, a significant critique emerges: international covenants, resolutions, guidelines, and principles appear ineffective or materially inconsequential (Schnitkes 2024). Several scholars have noted the limits of international law based on its weak enforcement mechanisms, especially in the United States, where there is no international court with compulsory jurisdiction over the U.S. for most human rights issues (Cassil 2001; Schnitkes 2024; Davis and Kaufman 2018; Mullins 2018; Resnick 2012). Other scholars point to the impossibility of implementing international human rights law when the U.S. Constitution, as the supreme law of the land, does not allow other treaties to override it (Cassil 2001; Glensy 2011; Paulson 2008). In practice, this means that the majority of international human rights law has only persuasive or moral value, not binding force in the United States.

These critiques have merit and provide supportive evidence of international law’s failure vis-à-vis the United States. However, dismissing international human rights covenants, resolutions, guidelines, and principles in their entirety overlooks the instances in which international pressure and legal instruments have successfully been used to bring activists, experts, and policymakers together to challenge domestic policies and state practices. Such dismissals overlook the reality that, despite their limited enforceability, these international frameworks serve as critical resources for advocacy, transnational coalition-building, and the reframing of domestic struggles within a global human rights paradigm. Therefore, recognizing the limited feasibility of international frameworks to affect U.S. legislation and political actions, especially now, does not mean abandoning them entirely. International human rights covenants, resolutions, guidelines, and principles can still serve as productive tools for exerting political pressure, establishing human rights standards, creating counternarratives, enhancing legitimacy, and driving long-term change. Situating anti-TGI legislation within the framework of international human rights enables scholars, policymakers, and activists to reconceptualize these laws not as isolated national issues but as part of broader patterns of structural violence and rights violations.

My objective in advancing arguments grounded in international covenants, resolutions, guidelines, and principles is to expand the legal and political discourse surrounding U.S. anti-TGI legislation beyond the confines of domestic law. Existing scholarship and advocacy around formal institutional reform have overwhelmingly emphasized national dynamics and political actors; this article offers a theoretical intervention that highlights the international dimensions and ramifications of U.S. federal and state governments’ contraventions of human rights obligations through anti-TGI policies. This work does not seek to provide prescriptive solutions. Instead, it aims to resituate debates around anti-TGI legislation within an international human rights legal framework. In a political moment defined by hostility toward the UN, multilateralism, and international coalition-building, engaging with the language of global human rights and healthcare may appear futile. However, I contend that one of the most significant barriers to securing institutional and legislative protections for TGI healthcare rights lies in the geopolitical and epistemological siloing that relegates such TGI human rights outside of international human rights, delegating them to domestic legislation. TGI healthcare is often seen as a personal choice rather than an inherent right and therefore not recognized as integral to global struggles for health, human rights, and protection from displacement.

Accordingly, this paper examines the potential to reframe U.S. anti-TGI legislation and the displacement it generates through the lens of existing international human rights instruments. The first section analyzes covenants, resolutions, guidelines, and principles affirming the right to health and healthcare, arguing that gender-affirming care must be recognized as a protected right under international law. Such recognition would provide additional leverage for advocates and legislators seeking to repeal discriminatory statutes. The second section considers the plight of TGI families and adults fleeing punitive state laws, contending that these individuals should be classified as internally displaced persons (IDPs) and thus entitled to international protection and resources. Reframing internal U.S. migration in this way compels both state and federal governments to acknowledge their obligations to ensure safety and humanitarian aid for those displaced by anti-TGI legislation.

2. Connecting International Resolutions on the Right to Health to Anti-TGI Legislation in the United States

As an influential member of the UN General Council and the UNHRC, the United States has a long history of co-drafting and signing international human rights covenants, resolutions, guidelines, and principles (Heyns and Viljoen 2001; Voss 2022). As noted above, the majority of signed human rights covenants and resolutions are still awaiting ratification by the United States Senate, rendering them unenforceable and easily overridden by Congress or ignored by the executive branch. Ratified international treaties are often non-self-executing, meaning they do not create enforceable rights in U.S. courts unless Congress passes implementing legislation. The United States is particularly resistant to adopt and comply with international treaties, even those that have been ratified (Bradley and Goldsmith 2018; Pollack 2015). This reality cannot be avoided, and international human rights covenants, resolutions, guidelines, and principles can easily be dismissed as performative and futile gestures of legal security and precedence. However, if the ultimate goal is not strict enforcement but rather the establishment of standards, then these international human rights frameworks do hold value. They create constitutional aspirations, serve as benchmarks for judging state behavior, and foster a shared language of human rights that transcends domestic politics. This is especially important when considering the right to healthcare and protection from discrimination regarding health. The U.S. Constitution does not explicitly protect health and the right to healthcare (Schweikart 2021). U.S. civil rights legislation is one area that activists and legal experts see as directly applicable to healthcare and protections against discrimination regarding the right to health. Scholars and activists have identified the Fourteenth Amendment’s Equal Protection Clause and Title VI of the Civil Rights Act as two guarantees of the right to healthcare free from discrimination (Denny 2018; Rosenbaum and Schmucker 2017). However, under both the Equal Protection Clause and Title VI, there is room for interpretation and for discriminatory laws to remain standing, as the focus is on intent to discriminate rather than the impact of discrimination. Healthcare regulations are generally reviewed by courts under the rational basis standard. Under this deferential test, a court asks only whether a conceivable legitimate government purpose exists and whether the law is reasonably related to that purpose. As a result, even healthcare laws that disproportionately harm certain groups are upheld as long as their defenders can provide any evidence, however weak, supporting a legitimate rationale, regardless of the law’s actual underlying purpose. Under the current Equal Protection doctrine, a law can predictably harm one group, be unevenly enforced, and even align with political hostility toward a population, as long as discriminatory intent is not proven.

The recent United States v. Skrmetti U.S. Supreme Court Case looked directly at whether a Tennessee Senate Bill (SB1) that banned gender-affirming medical care for transgender minors was a violation of the Fourteenth Amendment’s Equal Protection Clause. SB1 would allow certain treatments, such as hormone and puberty blockers, to be used for some medical conditions, but not to support a minor’s gender transition. The Supreme Court upheld the lower court’s decision that SB1 did not violate the Fourteenth Amendment’s Equal Protection Clause because the law officially banned usage based on age and medical use rather than explicitly on sex or transgender status (Redburn 2025; Murray and Shaw 2026). By applying rational basis review, the Supreme Court signaled that courts may uphold laws restricting gender-affirming care for transgender and gender-expansive minors as long as the law is not formally based on sex. This approach makes it easier for other states to defend similar bans against constitutional challenges. Critics of the decision argue that United States v. Skrmetti not only legitimizes restrictions on gender-affirming care for youth but also weakens constitutional protections for TGI communities by treating policies that disproportionately harm them as nondiscriminatory, despite their discriminatory effects.

The most substantial supports for the right to healthcare and protection against discrimination are found in the Affordable Care Act (ACA) (2010) and the Americans with Disabilities Act (ADA) (1990). The ACA is a federal statute that expanded Medicaid and Medicare coverage and included an individual mandate for insurance. While the ACA expanded coverage and addressed discrimination from insurance companies, states have the right to determine what is covered under Medicaid and Medicare (Wiegmann et al. 2021; Gage 2014). This creates a patchwork of coverage and protections, especially for TGI youths and adults accessing gender-affirming care (Gage 2014; Fore 2016). It is not a coincidence that states currently passing some of the most egregious anti-TGI legislation explicitly do not list gender identity as protected and covered under Medicaid or Medicare. The ADA protects against discrimination in healthcare and requires employers and institutions to be ADA-compliant. For the past decade, there has been a protracted legal battle over whether gender identity and gender dysphoria should be included in the ADA (Barry and Levi 2019; Szemanski 2020). Under Section 1557 of the ACA, health programs or activities receiving federal funding cannot discriminate. However, similar to the challenges with the Fourteenth Amendment’s Equal Protection Clause and Title VI of the Civil Rights Act, interpretation of what qualifies as protected from discrimination and a focus on intent rather than impact make Section 1557 challenging to enforce. Depending on the administration in charge, sex may be defined to encompass gender identity as well as sexual orientation. Under the current Trump administration, the definition of sex includes only biological sex, making it legal under the ACA to discriminate and deny healthcare coverage to transgender minors and adults (Jaramillo et al. 2025).

These institutional challenges mean health has increasingly been treated as an optional human right in the United States. Its definition often shifts with state politics and changing federal administrations. The effort to recognize gender identity as a protected class and to secure access to gender-affirming healthcare without discrimination is far from over. Health receives limited protection under federal and state law. By contrast, it is protected in several international covenants, resolutions, guidelines, and principles. International frameworks addressing the right to health and healthcare, along with the United Nations’ initial discussions on the protection of gender identity and access to gender-affirming care, offer a potential foundation for establishing clear standards. These standards help define both healthcare and the right to health for gender minorities. International human rights law, particularly the right to health, provides a potential counter-narrative to anti-TGI healthcare arguments. Gender-affirming care is often framed as controversial or optional and as imposing “radical gender ideology” on vulnerable youth and adults. Instead, like reproductive healthcare and abortion, it should be understood as a core component of comprehensive healthcare protected under international law.

The right to health plays a crucial role in influencing UN member states to adopt language and policies addressing healthcare (O’Connor et al. 2022). More formally known as the “right to the enjoyment of the highest attainable standard of physical and mental health” (Special Rapporteur on the Right to Health 2024), this has long precedence in international law. The Constitution of the World Health Organization (WHO 1946) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” From this definition, the United Nations (1948) Universal Declaration of Human Rights (UDHR) named health as part of the right to an adequate standard of living (United Nations 1948, Article 25). Health was identified as a human right in the United Nations (1966) International Covenant on Economic, Social and Cultural Rights (ICESCR), which the United States signed in 1977 but has not ratified. The United Nations (1989) Convention on the Rights of the Child states that children have the right to enjoy the highest attainable standard of health and access to healthcare services. The United States played a crucial role in crafting the Convention on the Rights of the Child. Like the ICESCR, the Convention on the Rights of the Child has yet to be ratified by the United States, although it has been signed. The United States is morally obligated to uphold both the ICESCR and the Convention on the Rights of the Child, having signed both. Moral obligation is not enforceable, but it does set a standard.

While international law can provide standards and language for gender-affirming care, it is also important to recognize that international law is a contested site. International law must be agreed upon and applied across countries with vastly different views on gender roles and identities, political systems and ideologies, and social attitudes regarding sexuality and human rights. For example, the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) issues recommendations and interpretations but lacks direct enforcement power. States can choose how much they comply with or contest these rulings. This is particularly evident in matters of gender identity and sexual orientation, which some states consider beyond CEDAW’s mandate.

Access to reproductive care and abortion provides another example of international law as a contested arena. Early human rights treaties did not explicitly mention reproductive care or abortion. However, since the establishment of the UDHR in 1948, feminists and medical experts have argued that its general rights to life, health, and privacy must encompass reproductive rights. Further support emerged with the adoption of the International ICESCR, particularly Article 12, which includes sexual and reproductive health. The adoption of CEDAW in 1979 explicitly addressed reproductive rights as a component of gender equality (Cook 2020).

Transnational feminist efforts around global reproductive rights were further reflected during the 1994 International Conference on Population and Development, which resulted in the first major global agreement framing reproductive health, including safe abortion where legal, as a human rights issue. This commitment was reaffirmed in the 1995 Beijing Platform for Action, which enshrined reproductive rights as essential to gender equality and women’s empowerment. Regional legal developments have bolstered these rights. For example, the European Court of Human Rights has recognized access to abortion under the rights to privacy (Article 8) and non-discrimination, while the Maputo Protocol obliges states to protect women’s reproductive rights, including safe abortion in certain circumstances. The international efforts by feminists, medical experts, and human rights advocates to advance international human rights policies and broaden the interpretation of the right to health to include reproductive care and abortion are a model that could be applied to advocating for gender-affirming care in international law (Pizzarossa 2018).

Some legislation and recommendations support the argument that if gender-affirming care is a human right protected legally, then countries must not only protect those seeking gender-affirming care but in fact provide that care (O’Connor et al. 2022). For example, ICESCR Article 12 states, “Everyone has the right to the enjoyment of the highest attainable standard of physical and mental health.” General comment 14 (adopted in 2000) emphasizes the protection of individuals’ agency to make decisions about their health and the prevention of harmful practices that undermine health. This aligns with arguments from health experts and activists that TGI youths and adults require access to gender-affirming care and the ability to make informed healthcare decisions (O’Connor et al. 2022). Access to gender-affirming healthcare increases overall physical and mental health while significantly reducing self-harm, suicide, addiction, homelessness, and unemployment (Mann et al. 2024). TGI patients’ agency in making decisions about their healthcare depends on providers being legally protected regardless of the patient’s age or gender identity. TGI patients’ agency also depends on legal protections addressing discrimination and stigma in medicine (Hughto et al. 2015). The ICESCR adds weight and legitimacy to these arguments and could potentially be leveraged in advocacy against anti-TGI state legislation.

To date, no UN General Assembly resolution protects gender identity and the right to gender-affirming healthcare; however, notable progress has been made in the UNHRC. In 2016, the UNHRC adopted a resolution for protection against violence and discrimination based on sexual orientation and gender identity, which the United States signed and supported. The 2016 resolution established an Independent Expert to report on the causes of violence and discrimination based on gender identity and sexual orientation and provide guidelines on human rights protections (UNHRC 2016). Shortly afterwards, the UN Special Rapporteur on the Right to Health argued that TGI identities should be declassified as a disease to reduce stigma (United Nations 2019). In 2019, the World Health Assembly adopted the eleventh revision of the International Classification of Diseases (ICD-11), which removed TGI identities and related categories from the mental and behavioral disorders chapter. This was crucial in recognizing human rights based on gender identity and access to gender-affirming care.

In 2022, the Independent Expert published a report in response to the 2030 Agenda for Sustainable Development. In addition to reporting violence and discrimination against sexual and gender minorities, the document argues that access to gender-affirming healthcare and steps to remove discrimination and stigma for sexual and gender minorities should be included in the 2030 Agenda for Sustainable Development Goal to “ensure healthy lives for all, leaving no one behind” (United Nations Independent Expert 2022):

The pledge to “ensure healthy lives for all, leaving no one behind” will remain lofty rhetoric unless it connects to the lived realities of those facing discrimination and violence based on sexual orientation and gender identity. Sexual orientation and gender identity are deeply rooted aspects of human personality that go to the core of every person’s right to the highest attainable standard of physical and mental health. If the SDG commitments are to be met by 2030, now is the time to unequivocally recognize LGBTI people as full subjects of rights and active agents of sustainable development.

(United Nations Independent Expert 2022, p. 3)

The warnings and advice of the Independent Expert for the 2030 Agenda for Sustainable Development are not an adopted resolution. The UN Sustainable Development Goals are not binding on member states and are unlikely to be achieved by 2030. However, even with this caveat, the language presented by the Independent Expert creates a strong argument for the right to gender-affirming care as crucial to human rights and development. Combining this with previous international resolutions protecting the right to healthcare and bodily autonomy regarding healthcare decisions creates a compelling argument against the current wave of laws within and outside of the United States restricting and criminalizing gender-affirming healthcare. Gender-affirming care is not an individual preference or elective healthcare but is grounded in international law and recommendations as a fundamental human right. Anti-TGI laws are not only counter to U.S. civil rights laws but also a direct violation of international resolutions and rules regarding the right to health and human rights protections for gender identity.

Coalitional work is essential in challenging healthcare discrimination and state violence. Everyone requires healthcare and the right to health. Black, Indigenous, Asian, Hispanic/Latine, disability, and women’s rights activists have pointed out that anti-TGI laws also put their communities at risk by enabling heterosexist, racist, and ableist healthcare discrimination (Galupo and Orphanidys 2022; Malatino 2021). The immediate crisis brought on by the wave of anti-TGI laws cannot overshadow the underlying root causes of anti-TGI violence, namely, the rise of nationalist populism, historic and ongoing white supremacy, heteronormativity, and cisnormativity. These factors, along with growing socio-economic disparity within the United States and globally, create circumstances in which TGI persons are harmed. The fight is not just against one persecutory law or state government harming TGI youths and adults. Instead, it is a more encompassing issue involving the right to health and human dignity that connects multiple communities transnationally—asking the fundamental question of who has the right to health, free from discrimination and violence. TGI, health, and civil rights activists must work collaboratively across borders to connect what is happening in the United States to international health inequality.

Shifting the focus from U.S. regional, state, and federal laws to the implications of international covenants, resolutions, guidelines, and principles also forces us to reframe migration in response to anti-TGI laws. LGBTQ+ migration within the United States is often framed in popular discourse as an individual journey based on choice or preference (Annes and Redlin 2012; Luibhéid and Chávez 2020). While a person’s agency is important in any migration story, framing LGBTQ+ migration only as individual choice overlooks the fear of persecution, material needs, and structural inequalities that underlie individuals’ need to relocate. Queer migration scholars have repeatedly shown that while individual choice is a factor, much of the internal LGBTQ+ migration in the United States is motivated by material needs, structural inequality, and fear of state and local violence (Ritholtz 2023). LGBTQ+ migration could be considered forced migration as much as a matter of individual agency. Even so, refugee and forced migration research has been slow to include internal LGBTQ+ migration as a form of forced migration and internal displacement.

3. Recognizing TGI Forced Migration and Internal Displacement

“No kid should be forced to leave the place where they grew up because of some stupid laws.”

Skyler Morrison, age 15, said this in an interview for the August 2023 issue of Teen Vogue (Latifi 2023). Morrison shared her family’s decision to leave Texas in 2015, when she was 9. At the time, the Texas House and Senate were trying to pass a series of anti-TGI bills that limited bathroom access based on sex and criminalized persons for using bathrooms designated for the opposite sex (SB6 & SB3). These bills ultimately did not pass, but several variations have been introduced. Since 2015, thirteen anti-TGI bills have passed into law. These laws include banning the majority of gender-affirming care for youths (SB 14 2023), banning transgender athletes from competing on teams matching their gender identity (SB 15 2023), limiting the definition of sex strictly to biological traits (HB 229 2025), and banning discussion of gender identity and other transgender-inclusive provisions in public schools (SB 12 2025). Over the last ten years, the media has paid increasing attention to TGI youths and adults forced to relocate to states with stronger TGI legal protections and greater tolerance. A 2025 Williams Institute study showed that forty-five percent of surveyed transgender adults have relocated or are considering moving to a location in the United States that provides more legal protections and affirming environments (Goldberg and Sears 2025). This number is a ninefold increase from the National Center for Transgender Equality’s 2022 survey, which showed that only five percent had moved due to anti-TGI legislation (NCTE 2022). This number will continue to grow as the amount of anti-TGI legislation increases. Despite growing numbers of TGI families and communities migrating to different parts of the country, media coverage has primarily focused on individual experiences and decisions to move. As more TGI communities are forced to leave states with anti-TGI legislation, this is no longer a story about a select group of individuals migrating. Rather, this is a significant population of displaced persons sharing a common impetus for migration. What protections, then, do displaced TGI persons have as a distinct population with a shared experience of social and state violence against them? What are our federal and state governments’ obligations and responsibilities to displaced TGI persons?

To begin this exploration, we need to interrogate the distinctions of what displacement is and who is recognized as deserving of rights and protections. In international and domestic legislation, displacement usually refers to people forcibly displaced from their country of origin. The UN’s 1951 Refugee Convention defines refugees as persons displaced outside their country of origin owing to a “well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion” (UNHCR 1951). In 1990, the United States included sexual orientation in the category of a particular social group, determining that this was immutable and grounds for asylum (Llewellyn 2021). Since 2000, the United States has recognized TGI asylum seekers as a social group that deserves protection based on gender identity. However, refugee and queer scholars have repeatedly noted that heteronormativity and cisnormativity within U.S. immigration processes make it challenging or impossible for many TGI individuals to make successful asylum claims (Llewellyn 2021). Nonetheless, it is important to examine the dividing line between refugees and forced migration within the United States. What legal and advocacy possibilities exist when we expand our understanding of refugees to include those forcibly relocated within the United States based on fear of state and social persecution? What international protections are there for IDPs, and how could these be applied to TGI communities fleeing anti-TGI laws?

The inspiration to explore these questions comes from Ritholtz’s (2023) article, in which they argue that queer and TGI youth homelessness should be considered forced migration akin to the understanding of refugee migration. Ritholtz argues there is an inherent “epistemological cisheteronormativity” (Ritholtz 2023, p. 1859) underlying refugee studies that makes queer and TGI displacements invisible to legal and policy discussions around refugees and forced migration. Those in the field of refugee studies act as “gatekeepers of legitimacy: whom they study becomes a humanitarian subject worthy of protection—and subject to intervention—by the international community” (Ritholtz 2023, p. 1857). While refugee research has expanded within the past twenty years to include studies on LGBTQ+ asylum seekers, much of the work published focuses on specific immigration pathways that do not fully encompass the many forced migrations marginalized LGBTQ+ communities make. People who are forced to migrate outside of their country but do not seek asylum are often excluded, as are those forcibly displaced within their country because of state and social persecution.

The political and legal framing of refugees and persecution as excluding U.S. citizens contributes to the invisibility of queer and TGI internal displacements in refugee research and policy (Ritholtz 2023). “Refugee” is a legal term and an identity marker defined by international interests to geopolitically separate populations and obligations. Defining refugees as external to the state in which they are claiming asylum grants the receiving state the authority to determine who is worthy of protection. This works in favor of Western countries, where popular media and national policy often depict refugees as coming from the Global South, although most refugee displacement is happening between countries in the Global South. Overlooked in this narrative are Western states’ accountability for and contribution to the economic, political, and environmental conditions that force people to migrate and become refugees. This narrative also allows Western nations to ignore domestic policies that contribute to economic and societal disparities that cause unlivable conditions for their own marginalized citizens.

Persecution is a crucial factor in determining whether one is granted asylum. To be granted asylum, a claimant must show credible evidence of or fear of persecution. However, just as geopolitical biases shape the understanding of who a refugee is, the definition of persecution is also subjective to underlying biases (Llewellyn 2021). The U.S. Board of Immigration Appeals (BIA) defines persecution as harm or suffering inflicted upon an individual to punish them for possessing a belief or characteristic the persecutor seeks to overcome. The harm or suffering inflicted does not have to be punitive and encompasses more than physical damage. Non-physical harm may include “the deliberate imposition of severe economic disadvantage or the deprivation of liberty, food, housing, employment or other essentials of life” (U.S. Citizenship and Immigration Services 2025). Essentials of life include access to healthcare. While civil rights protections address crimes against humanity, persecution is primarily framed in the U.S. legal and political systems in the context of immigration. It occurs outside of the United States as something external for which the country may grant asylum if the applicant can credibly prove it. However, similar conditions that cause people to experience harm and suffering through discriminatory laws, police brutality, social violence, and structural inequality are present domestically. If they were happening in another country, anti-TGI legislation and the related anti-TGI social and state violence could be considered grounds for a persecution claim. Why, then, is the U.S. federal government not applying the same language and responsibility to its own citizens currently experiencing state and social persecution? Likewise, what is the responsibility of the international community in addressing anti-TGI persecution in the United States? Despite the Canadian government’s warning for LGBTQ+ citizens traveling to the United States, U.S. LGBTQ+ asylum seekers are rarely granted asylum in Canada or other countries. As in the United States, claiming asylum in Canada or other Western States is not a straightforward path, even for asylum seekers with economic and political resources. Asylum seekers coming from the United States have the additional challenge that their claims and fear of persecution are not recognized in the face of U.S. economic and geopolitical dominance. Instead, it is assumed that people experiencing persecution in the United States can simply relocate to another area within the country and receive protection and resources. This assumption is simplistic and overlooks institutional and material barriers to internal migration. It also erases the underlying fear and experiences of persecution present in the United States that cause many LGBTQ+ migrations to be forced.

In the current environment, the U.S. government and the international community do not recognize that the human rights of refugees and those experiencing persecution apply to U.S. legal residents, especially LGBTQ+ citizens. However, in addition to the legal and policy definitions of “refugee” and “asylum,” forced migration encompasses the spectrum of volition and coercion that causes individuals to relocate (Ritholtz 2023; Luibhéid and Chávez 2020). Forced migration is therefore a helpful concept for better conceptualizing TGI internal displacement in the United States in response to state and social persecution. TGI persons are structurally vulnerable to physical and emotional suffering because of cisheteronormative stigma and violence (Gamarel et al. 2021). Intertwined with anti-TGI violence are the higher rates of homelessness, poverty, and unemployment TGI individuals experience compared to their cisgender peers (Glick et al. 2021; Carpenter et al. 2020). Many TGI individuals leave their areas of residency because of limited or lacking resources and protections. Sacrificing one’s home and housing, moving away from family and close relationships, and leaving one’s education and employment to access necessary gender-affirming healthcare and protections against anti-TGI discrimination and violence do not indicate a matter of choice.

The anti-TGI laws currently being introduced make migration a choiceless decision for many caregivers to TGI youth facing potential prosecution and state removal of their children for seeking gender-affirming care. Moving based on fear of violence, criminalization, and lack of access to healthcare is forced migration. Individuals are internally displaced because institutional resources and legal protections are not in place. Reframing migration in response to anti-TGI legislation as forced migration creates a new understanding of the rights of those internally displaced by these laws.

As of June 2023, IDPs account for fifty-eight percent of all forcibly displaced people worldwide (UNHCR 2023), showing that most people who are forced to flee never cross an international border. The UN defines internal displacement as:

Persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized border.

(UNHCR 2024)

Internal displacement is often depicted in the international media and framed in international human rights discussions as a humanitarian issue in the Global South caused by civil unrest, political corruption, economic disparities, and ecological disasters (Fonkem 2020; Adeola and Orchard 2020). This is partly because UN data on the estimated IDP population come primarily from those residing in the Global South. IDPs living in the Global North and Western states are rarely included in international assessments of IDPs, partly because of the limited tracking and reporting of IDPs within Western and Global Northern countries. Displacement is happening within these countries, but their governments rarely recognize it.

The International Displacement Monitoring Centre (IDMC) estimates there were 675,000 displaced persons in the United States as of 2022 (IDMC 2022). However, the IDMC notes that this number is likely underestimated because of the lack of systemic monitoring of displacement within the United States. The U.S. federal government has no delegated office to track internal displacement and has yet to offer consistent reporting on the number of IDPs. Tracking of IDPs has primarily been limited to those displaced by major environmental disasters such as tornadoes, wildfires, flooding, and earthquakes. The Federal Emergency Management Agency (FEMA) is the only government program offering any information on the number of displaced people, in this case based on mandatory evacuation orders due to major environmental disasters. The American Red Cross is the largest civil organization tracking IDPs but, like FEMA, it primarily reports on those displaced because of major environmental disasters.

Limiting tracking of IDPs to those displaced by environmental disasters erases countless historical and ongoing displacements brought on by persecutory laws, state-enacted violence, and social inequality. In the context of the United States, internal displacement is intertwined with historical and current injustices (Freier et al. 2020). People have been internally displaced since the colonization of the Americas and the U.S. occupation of Native American traditional territories. However, there are no definitive laws within the United States to protect the rights of those internally displaced. Examining international legislation regarding IDPs is also a challenge, as there are no legislative or dedicated UN agencies responsible for IDPs. The lack of global legislation and institutional accountability is a growing problem, especially as estimated IDP populations grow every year. However, agreed-upon international principles do emphasize states’ obligations to provide protection and assistance to those internally displaced. Most significant are the 1998 UN Guiding Principles on Internal Displacement (UNHCR 1998).

The thirty Guiding Principles were a milestone in establishing a normative framework for protecting IDPs. They compiled existing international human rights laws and applied them to IDPs, arguing that they are guaranteed the same rights and protection as internationally displaced persons. The Guiding Principles reiterate that the state, not the international community, is primarily responsible for addressing and preventing displacement. The first principle emphasizes that IDPs should “enjoy, in full equality, the same rights and freedoms under international and domestic law as other persons in their country.” Principle 3 states that “national authorities have the primary duty and responsibility to provide protection and humanitarian assistance to internally displaced persons within their jurisdiction.” Other principles include a range of economic, cultural, social, and civil rights, including the right to employment, the right to be protected from violence, the right to education, the right to freedom of movement and residence, and political rights (Principles 10 through 20). The Guiding Principles also emphasize state governments’ responsibility for IDPs’ voluntary and safe return or resettlement, including recovering lost property and possessions and compensation or reparation when restitution is impossible (Principles 28 through 30).

The Guiding Principles are not legally binding, and member states are not obligated to adhere to them. Despite this lack of legal enforcement, recognizing the U.S. government’s role in protecting the rights of IDPs provides language that advocates and legislators could use to address the systemic violence of anti-TGI legislation. The U.S. government is responsible for the safety and well-being of U.S. IDPs. The international community must step in if the U.S. government cannot provide resources and protection. TGI internal displacement is one of many acts of violence that occur when anti-TGI care legislation is enacted. There is value in distinguishing TGI internal displacement as a unique violence the U.S. government is responsible for addressing. This reframes TGI internal displacement from an unfortunate consequence of anti-TGI legislation to a violation of internationally set principles that guarantee the rights and protection of those displaced. TGI individuals are a specific population of IDPs with rights agreed upon in international principles. These rights include protection, humanitarian assistance, and reparations. The federal government and the international community are obligated to address the conditions that cause TGI internal displacement and to work toward improving conditions so that TGI IDPs can return to their home states.

Recognizing TGI people’s relocation to different states as forced migration and internal displacement also raises the receiving states’ responsibility to provide protection and resources. As of January 2026, thirteen states and the District of Columbia have declared themselves transgender sanctuary states for fleeing TGI youths and adults. These states have enacted shield laws so that if a person travels from a state where gender-affirming healthcare is banned to receive care, both the individual and their care providers are protected against civil or criminal charges from the state where gender-affirming healthcare is criminalized.

It is one thing to offer sanctuary from potential prosecution in a neighboring state; it is another to provide institutional and structural resources so individuals can receive gender-affirming care after relocating. States offering transgender sanctuary are not committing themselves to providing the institutional infrastructure and resources for TGI persons to access and receive gender-affirming care easily. California was the first state to provide transgender sanctuary in 2022. However, it is a state with significant health disparities, economic inequality, and housing shortages that cause TGI Californians significant hardship (Johnson 2022; Trans-E-Motion 2021). In many areas of California, predominantly rural and low-income areas, access to gender-affirming care providers is limited or nonexistent (Trans-E-Motion 2021). Recent research has shown the compromises and disadvantages TGI internal migrants experience when relocating to another state to receive gender-affirming care. A study of TGI adult internal migrants in the San Francisco area showed they faced significant loss of income and unemployment, housing insecurity, and further stressors to their health and well-being (Gamarel et al. 2021). Much of this was attributable to the high cost of living in the San Francisco area and the long waiting period to establish access to healthcare and meet with a gender-affirming care provider. These added costs are described as a “tax” that TGI internal migrants must pay to get the gender-affirming healthcare they desperately need. It becomes a paradox of trading one form of health security for another, a trade-off in which, inevitably, individuals experience precarity and structural vulnerability that affect their health and wellness (Gamarel et al. 2021). Limiting transgender sanctuary to legal protections from other states’ anti-TGI laws does not protect a TGI person’s health and well-being. States like California also need to commit resources to address systemic health disparities, including but not limited to building capacity for more gender-affirming care providers across the state, developing more low-income and TGI-inclusive housing and shelters, and working with state and civil organizations to address violence and discrimination against marginalized TGI communities.

Connecting the rights of IDPs with what is happening in the United States is also a call for transnational coalition work. Refugee and forced migration scholars and activists must challenge underlying biases and hierarchies that dismiss or overlook acts of persecution against TGI communities in the United States and similar Western states. IDP scholars, organizations, and activists are also encouraged to broaden their definition and understanding of internal displacement to include the various forms of LGBTQ+ forced migration happening globally and within Western states. Both government and civil organizations must implement better tracking and take accountability to understand how sexuality and gender impact internal displacement. TGI, LGBTQ+, and civil rights activists in the United States could position their fight against anti-TGI legislation in part as a battle against displacement and therefore call for government accountability.

4. Conclusions

In this article, I explored the implications and possibilities of connecting international covenants, resolutions, guidelines, and principles around health and displacement to the current wave of anti-TGI laws in the United States. My arguments are theoretical and have yet to be taken up by legal experts, legislators, and activists in a substantial way. Most of the international covenants, resolutions, guidelines, and principles I present are not legally binding and are unenforceable. However, even without legal enforcement, there is potential to connect international covenants, resolutions, guidelines, and principles to the legal, institutional, and social harms happening within the United States. At the very least, these connections highlight the paradox of the United States endorsing human rights principles and resolutions internationally but ignoring these same principles and resolutions for its own citizens. Human rights scholars and activists have often raised this paradox, but LGBTQ+ persons are rarely included in this conversation.

Connecting international covenants, resolutions, guidelines, and principles to anti-TGI legislation reframes the issue as a broader human rights crisis concerning the legal right to health and protections against displacement. However, a legal reframe does not in itself address heteronormative, racist, and cisnormative assumptions about gender-affirming healthcare and migration as a choice. This paper focused on formal institutional and legal change and advocacy. However, activists and organizations are also creating informal change by promoting a discourse of respect and equality for the TGI community. Marginalized TGI communities offer the critique that gender-affirming care was impossible for them well before state bans, as individuals must have inherent privileges and advantages to obtain gender-affirming care or relocate to an area where gender-affirming care is available. The poor status of TGI health both before and after the introduction of anti-TGI laws needs to be at the forefront when mobilizing against these laws. Overturning anti-TGI legislation does not guarantee better quality of life for many TGI communities.

International covenants, resolutions, guidelines, and principles could be used to advance the conversation about expanding legal and institutional TGI human rights in the United States. Reframing anti-TGI laws and their effects on TGI communities in the context of international covenants, resolutions, guidelines, and principles for healthcare and displacement encourages scholars and activists to look at epistemological boundaries that erase LGBTQ+ experiences. This reframing raises questions about who is deserving of the right to health and who has the right to protection from being displaced, as well as when the state must recognize persecution and how domestic persecution is silenced in political discourse and legislation. These questions should encourage scholars, legislators, and activists to question current legal and international framings around the right to health and protection for those displaced and build transnational coalitions around the underlying causes of anti-TGI discrimination and violence.