Proposition 135: Prohibit Surgery on Minors in Response to Perception of Sex or Gender

Proposition 135 would prohibit surgery on minors that alters their biological sex characteristics in response to their perception of sex or gender. It would also bar state or federal funds, Medicaid and insurance coverage from paying for these surgeries. The measure allows male circumcision and treatment for medically verifiable disorders of sex development. A YES vote enacts these prohibitions. A NO vote keeps Colorado law, which protects access to these surgeries and lets insurance pay for them.

The measure would minimally increase workload and costs for the Department of Regulatory Agencies to update rules and handle complaints. State and local agencies that employ health care professionals would update their policies, and legal costs could rise if noncompliance is alleged. Assuming compliance, the effect on state and local spending is expected to be minimal. State health programs and employee health insurance spending may slightly decrease, with overall savings expected to be minimal.

What medical treatments are prohibited by Proposition 135?

The measure prohibits surgery on minors for the purpose of altering biological sex characteristics as a treatment in response to a minor’s perception of sex or gender. The measure does not list specific surgical procedures that are prohibited; instead, the prohibition is based on the reason that a surgery is performed on a minor. The prohibition includes gender-affirming surgeries, which are a range of procedures that may be provided to transgender individuals to make their physical appearance match their gender identity. Examples include altering, removing, or reconstructing sexual and reproductive organs; modifying body shape; changing facial appearance; or altering vocal characteristics. The measure may also limit other surgeries for minors, including non-transgender minors, if the treatment is interpreted as being in response to the minor’s sex or gender perception.

Proposition 135 allows male circumcision and treatments for medically verifiable disorders of sex development or acquired physical or chemical abnormalities. Non-surgical gender-related treatments, such as social transition options and counseling, are also not restricted by the measure.

How does Proposition 135 change coverage for these procedures?

Currently in Colorado, gender- and sex-based surgeries that are medically necessary may be covered by private health insurance or a public health care program, or be paid for out-of-pocket. The measure bans the use of state or federal money, Medicaid reimbursements, and private health insurance to pay for the prohibited surgeries.

How often are these procedures performed on minors in the United States?

It is unknown how many minors receive gender- and sex-based surgeries that would be prohibited under the measure. However, one study found that gender-affirming surgery for transgender minors in the United States is rare. The study, from researchers at Harvard University, examined 2019 health insurance claim data and found that for every 100,000 youths aged 15 to 17, an estimated 2.1 youths who identified as transgender or gender diverse had at least one gender-affirming surgery. For youths aged 13 to 14, these surgeries are even more rare, with 0.1 youths having a surgery per 100,000 youths (or 1 in a million). Researchers found no cases of gender-affirming surgeries being performed on youths aged 12 and younger.

The three large pediatric surgical providers in Colorado—Children’s Hospital Colorado, Rocky Mountain Children’s, and Denver Health—report that they do not perform gender- or sex-based surgeries on transgender patients under 18 years of age.

FINANCIAL IMPACT STATEMENT

State and Local Government Spending

Proposition 135 will minimally increase workload and costs for the Department of Regulatory Agencies, which regulates health care professionals and insurers, to update rules and materials pertaining to gender- and sex-based surgeries and to handle complaints if prohibited surgeries are performed or paid for. Similarly, various state and local government agencies that employ health care professionals, such as the Department of Human Services and county hospitals, among others, will have additional workload to update their policies to ensure that their employees follow the measure. Legal costs may also increase for the state and local governments to respond to any allegations of noncompliance. Assuming health care professionals, insurance companies, and government agencies comply with the measure, any impact on state and local spending is expected to be minimal.

Proposition 135 may also slightly decrease state spending on health programs and employee health insurance from no longer paying for certain surgeries for minors related to gender perception.

Specifically, to the extent the state Medicaid program covers these surgeries for minors, spending will decrease. Similarly, if private insurance companies no longer cover these surgeries, it may minimally contribute to lower health insurance premiums for state and local governments. Overall, any savings are expected to be minimal.