Puerto Rico’s Controversial Ban on Gender Transition Surgery

In July 2025, Puerto Rico made headlines by enacting one of the most restrictive laws in the United States and its territories concerning gender transition surgery and related care.

Signed into law by Republican Governor Jenniffer González-Colón, Senate Bill 350 prohibits hormone therapy and gender-affirming surgeries for transgender individuals under the age of 21. This legislation has ignited a fierce debate, touching on issues of constitutionality, medical necessity, and ethical considerations.

Details of the Ban: Who Does It Affect?

The Puerto Rican law is sweeping in its scope, banning gender-affirming care—including hormone therapy and surgeries—for all individuals under 21. This includes both minors (those under 18) and young adults up to age 21, as the age of majority in Puerto Rico is 21, unlike the mainland U.S., where it is typically 18.

The law imposes harsh penalties on healthcare providers who violate it: a $50,000 fine per incident, up to 15 years in prison, and permanent revocation of medical licenses. Public funds are also barred from being used for such treatments, effectively cutting off access for many.

This ban stands out as one of the strictest in the U.S., surpassing laws in states like Alabama and Nebraska, which cap restrictions at age 19, and even proposals in states like Oklahoma and Texas, which have considered bans up to age 26.

By extending the restriction to 21, Puerto Rico’s legislation affects not only children and adolescents but also young adults who, in many legal contexts, are deemed capable of making significant life decisions.

Constitutional Concerns: An Unprecedented Intervention in Minors’ Lives

The ban’s impact on minors—those under 18—raises profound constitutional questions, particularly given their lack of legal autonomy in other areas. In Puerto Rico, as in the rest of the U.S., minors cannot vote, purchase alcohol, enlist in the military, or consent to many other activities until they reach a designated age of majority or consent.

Yet, prior to this law, transgender minors could, with parental consent and medical oversight, access gender-affirming care, including surgeries in rare cases. The new law strips away this possibility, prompting critics to argue that it is unconstitutional by every metric.

Inconsistency with Age of Consent Laws

Consider the inconsistency: a 17-year-old cannot legally drink a beer or cast a ballot, activities with far less permanent consequence than surgery, yet the state now asserts that such a minor should not have access to gender transition surgery—even if deemed necessary by medical professionals and supported by parents.

This intervention overrides the rights of parents to make medical decisions for their children, a principle long upheld in U.S. law. It also clashes with the concept of bodily autonomy, suggesting that the government, rather than families and doctors, should dictate what is permissible for a minor’s body.

Violation of Equal Protection

The law’s targeting of transgender individuals could violate the Equal Protection Clause of the U.S. Constitution. By singling out gender-affirming care while allowing other medical procedures for minors—such as cosmetic surgeries or treatments for chronic conditions—it discriminates against a specific group based on their gender identity.

The U.S. Supreme Court’s 2025 decision upholding Tennessee’s ban on gender-affirming care for minors ruled that such laws do not constitute sex-based discrimination. However, Puerto Rico’s extension to age 21 and its unique status as a territory may invite fresh legal scrutiny, especially if courts view the law as disproportionately burdensome to a protected class.

A Paternalistic Overreach

For minors, who lack the legal capacity to consent independently, the ban represents a paternalistic overreach. It assumes that neither they, their parents, nor their doctors can be trusted to make informed decisions about their healthcare.

This contradicts established legal precedents that grant parents significant latitude in raising their children, including decisions about medical treatment. The Puerto Rico LGBTQ+ Federation has labeled the law “cruel and inhumane,” vowing to challenge it in court on these grounds.

Medical and Psychological Perspectives: Is Gender-Affirming Care Necessary?

Proponents of the ban argue that gender transition surgery is unnatural, not medically necessary, and leads to lifelong medical and mental health complications. They contend that minors, unable to fully grasp the consequences, should not undergo irreversible procedures. Instead, they advocate addressing gender dysphoria—the distress caused by a mismatch between one’s gender identity and assigned sex—through alternative means, such as therapy.

The Case Against Medical Necessity

Critics of gender-affirming care assert that it is not a cure but a drastic intervention with uncertain outcomes. Surgeries, such as mastectomies or genital reconstruction, are permanent and require ongoing hormone therapy, which can carry risks like infertility, cardiovascular issues, and bone density loss.

They argue that gender dysphoria in minors often resolves with puberty—citing studies suggesting that many children who experience it later identify with their birth sex—and that surgery preempts this natural resolution. Mental health issues, they say, are better managed through counseling rather than physical alteration.

The Medical Consensus

However, this view is at odds with the consensus of major medical organizations. The American Medical Association, American Academy of Pediatrics, and World Professional Association for Transgender Health classify gender-affirming care as medically necessary for many transgender individuals with gender dysphoria.

For minors, treatment typically begins with puberty blockers—reversible drugs that delay physical changes—followed by hormone therapy in adolescence, with surgeries reserved for older teens or adults after extensive evaluation. These interventions are tailored to each patient, guided by evidence that they reduce depression, anxiety, and suicide risk.

Ethical Dimensions: Discrimination or Protection?

Ethically, the ban is a lightning rod. Supporters frame it as a protective measure, safeguarding minors from decisions they may regret. They argue that the state has a duty to prevent harm, especially for those not of the age of consent.

Opponents, however, see it as discriminatory, targeting a vulnerable minority and denying them equal access to healthcare. The law’s extension to young adults up to 21 amplifies this critique, as it restricts individuals who, in many contexts, are considered capable of self-determination.