Republican state Sen. Jack Johnson stood on the Tennessee Senate floor last month to open the discussion on a bill he is co-sponsoring. The measure would limit gender-affirming care such as puberty blockers, hormone therapy and surgeries for minors.

“Let’s put children first and look out for them first and let them make those decisions as adults,” he said. “I support your right to do so, when you’re an adult, not when you’re a child and you do not have the mental capacity to do so.”

But Johnson is also backing another bill, HB1215, that would effectively cut off access to gender-affirming care for low-income people, including adults. The measure prohibits Tennessee’s Medicaid program from working with health insurance companies that cover gender-affirming care.

As of late February, Republican lawmakers in at least five states have introduced legislation that would limit such care for adults. Until this year, most proposed restrictions on transition-related care targeted people under 18. Some of the new measures prohibit it for individuals up to age 21, while others block Medicaid from covering for it for all ages.

“It’s interesting that initially we heard that this was a thing to protect youth, but now we are seeing that it’s really about all transgender people,” Rep. Gloria Johnson (D-Knoxville) said while HB1215 was being discussed on Feb. 21 in the Tennessee House.

“Last year, the rhetoric was to protect kids, but now they are going after adults,” said Allison Chapman, a legislative researcher and transgender rights advocate based in Virginia.

In Oklahoma, House Republicans also approved a bill Tuesday that would prohibit any facility that receives public funds from offering gender-affirming care for minors or adults, as well as blocking insurance coverage for it. Another bill would make it a felony for a physician to provide transition-related hormone treatments or surgeries to anyone under the age of 26. In Kansas and Mississippi, legislators wanted to ban gender-affirming care for people up to age 21. In South Carolina, a measure would block the state’s Medicaid program from covering any transition-related medications or procedures.

Tennessee Rep. Tim Rudd (R-Murfreesboro), who supports HB1215, said on Feb. 21 that the bill was not making transgender health care illegal because people could still obtain it privately. Instead, it was “simply taking away a service” that does not align with the “values of most Tennesseans.”

But Angel Luci Pellegrino, a 38-year-old transgender man based in Chattanooga, Tenn., said the measure, if passed, would probably end his access to gender-affirming care. “My doctor informed me that if this bill passes, insurance will no longer cover my medicines, my doctor’s appointments and my laboratory tests,” he said, adding that he is on disability and “can’t afford private health care.”

Transgender advocates said the push to extend restrictions to those over 18 should not come as a surprise. They view bans on gender-affirming care for minors as part of a broader attack on transgender rights.

“Both kinds of legislation [for minors and adults] are equally detrimental for the overall health of trans people,” Chapman said. “First, we were fighting for the kids; now we will fight for ourselves.”

Terry Schilling, president of the conservative American Principles Project, said his organization wants gender-transition procedures for minors and adults to be unthinkable in the future. “I want transition care to be thought of as horrific medical practices that happened in the past,” he said.

Focusing on protecting children first was obvious, according to Schilling, because “they are so vulnerable.” But when it comes to adults, he said, he doesn’t want to ban gender transition care but rather use the threat of malpractice suits to discourage health-care providers from offering it. He said he wants to make it so that “anyone who is forced into these surgeries can become a millionaire later.”

The American Medical Association, the American Psychological Association, the Endocrine Society and other major medical organizations oppose restrictions on gender-affirming care. The American Academy of Pediatrics released a statement in August that called such care “medically necessary and appropriate” for some minors and criticized the “rampant disinformation” spread by those seeking restrictions.

Supporters of bans on gender-affirming care for youths have argued that minors are not capable of making decisions about gender transition, even though those decisions are made with parents and health-care providers. They cite the potential long-term effects of and possible regret over treatments such as taking hormones and breast-removal surgery. Some legislators argue that the concerns about adolescent judgment also apply to young adults.

Oklahoma state Rep. Jim Olsen (R), who wrote a bill that prohibits health-care professionals from providing referrals for puberty blockers, hormones and gender-transition surgeries to trans youths and adults up to the age of 21, said he wanted to match the age limit for drinking alcohol.

“It’s a very big, big decision, so people are realizing that you should be older when you make it,” Olsen said. The legislator also wrote a bill to lower the minimum age to carry a firearm from 21 to 18.

Olsen is aware that Republican legislators in Oklahoma introduced three bills last year to restrict transition care, two focused on adolescents and minors and one aimed at restricting gender assignment medical treatment until age 21. All three bills were dead by May. But he said his measure is likely to have more support because House and Senate leaders and the governor are more favorable toward it than for previous efforts. “All this gives us cause for hope,” he said.

So far, Republican legislators in four states have passed bans on gender-affirming care for minors: Utah and Mississippi this year and Arkansas and Alabama last year. (Utah, Mississippi and Arkansas define minors as under 18, while in Alabama, a minor is under 19.) The laws in Arkansas and Alabama are tied up in court. In Florida, the state Board of Medicine has approved a ban on gender-affirming care for minors, and the state no longer allows Medicaid to cover it for anyone, regardless of age.

The Endocrine Society has called the Florida ban on gender-affirming care for minors “blatantly discriminatory” and said it “contradicts medical evidence.” Major medical groups have also filed an amicus brief in support of Medicaid recipients in Florida who are challenging the state’s ban on Medicaid coverage for gender-affirming care in court. Despite the lawsuit, a judge has allowed the policy to take effect.

Transgender advocates say laws that prohibit or limit access to gender-affirming treatments will probably require transgender people to stop or delay transition-related care.

“A transgender woman who is cut off from her hormones may experience facial hair, increased testosterone and a deepening voice,” said Erin Reed, a D.C. area researcher who tracks transgender legislation. “This could be deeply traumatic for her.”

In Tennessee, Pellegrino is watching what is happening at the state Capitol with growing apprehension.

A suicide survivor, he said he can’t imagine how it will feel if the state “forces him out of transitioning.”

With his limited resources, he said, he can’t afford to leave Tennessee. So he is searching for a legal recourse to access gender-affirming care in case the bill becomes law.

“Transitioning was not a cosmetic procedure for me; it was lifesaving treatment,” he said. “I am in a really dark place with this news right now.”