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

An estimated 1,800 to 4,200 transgender youth live in Colorado, but the state's major pediatric hospitals do not perform the surgeries this measure would prohibit on minors.

According to demographic estimates published between 2020 and 2023 by the Williams Institute at the UCLA School of Law, Colorado is home to between 1,800 and 4,200 transgender youth ages 13 to 17. This population size is relatively average compared to other states; for example, California has over 22,000 transgender youth while Wyoming has fewer than 200.

However, the gender-related surgeries targeted by Proposition 135 are exceptionally rare. According to the 2026 Colorado State Ballot Information Booklet, these procedures occur nationally at a rate of about 2 per 100,000 youths aged 15 to 17. Within Colorado, the state's three large pediatric surgical providers report that they do not perform these procedures on patients under 18.

Because these surgeries are already not happening at major Colorado facilities, opponents argue the measure is an unnecessary overreach that could interfere with families' medical decisions. Supporters argue that a proactive legal ban is still necessary to guarantee that minors cannot undergo irreversible physical changes before adulthood, regardless of current hospital policies.

Under current Colorado law, gender-related surgeries for minors are legal and protected, but in medical practice, major pediatric hospitals in the state do not perform them.

State law explicitly protects access to gender-affirming medical care for minors. A 2025 state law also mandates that public and private health insurance providers cover these procedures when a doctor determines they are medically necessary.

However, medical practice guidelines and hospital policies make these surgeries exceptionally rare for patients under 18. According to the 2026 state Blue Book and a 2024 Harvard study, the rate of gender-affirming surgeries for youths aged 15 to 17 is about 2.1 per 100,000. When surgery is considered for older adolescents, medical guidelines require parental consent, years of therapy, and extensive consultation with medical experts.

In Colorado, the state's three largest pediatric surgical providers, including Children's Hospital Colorado and UCHealth, state they do not perform gender-affirming surgeries on minors. Supporters of the ballot measure argue that a legal ban is still necessary to ensure minors cannot make permanent surgical decisions before adulthood. Opponents argue the ban would interfere with careful decisions made by families and doctors, and could inadvertently restrict surgeries for non-transgender youth.

As of 2026, 27 states have enacted laws banning or restricting gender-affirming medical care for minors, and the U.S. Supreme Court upheld these bans in a 2025 ruling.

According to tracking by KFF and the Williams Institute, these 27 states had passed their restrictions by early 2026. In June 2025, the Supreme Court ruled 6-3 in United States v. Skrmetti that state bans on gender-affirming care for youth do not violate the U.S. Constitution. Following this ruling, most state bans are currently in effect, though a few remain blocked by lower courts based on state-level legal claims.

Colorado currently does not ban these procedures. In contrast to the states with bans, 17 states and Washington, D.C., had passed "shield laws" as of early 2026 to protect access to gender-affirming care and legally protect the doctors who provide it, according to the Williams Institute.

Supporters of state bans argue that the government must step in to protect minors from irreversible physical changes before they are old enough to fully consent. Opponents argue that these laws interfere with the rights of parents to make medical decisions for their children and note that gender-related surgeries on minors are already exceedingly rare.

Major medical associations generally recommend deferring genital surgeries for minors until adulthood, though their guidelines differ on chest surgeries and overall care.

• American Medical Association and American Society of Plastic Surgeons: In February 2026, both organizations updated their stances to recommend that gender-related surgeries for minors generally be deferred until adulthood, or age 19 for ASPS. They cited a lack of clear evidence regarding long-term outcomes.
• American Academy of Pediatrics: The AAP supports gender-affirming care but stated in 2026 that its guidance does not include a blanket recommendation for surgery for minors. The organization emphasizes that treatment decisions should be made by patients, their families, and their doctors.
• Endocrine Society: Its current guidelines recommend waiting until age 18 for genital surgery. However, the society notes that some surgeons may perform chest surgeries on minors who are emotionally mature enough to understand the risks.
• World Professional Association for Transgender Health: In its 2022 Standards of Care, WPATH removed specific minimum age requirements for most surgeries. The guidelines state that chest surgeries can be considered for minors on a case-by-case basis, while genital surgeries are typically deferred until the legal age of majority.

There is no exact dollar figure available for how much Colorado Medicaid and the state employee health plan spend annually on gender-related surgeries for minors, but state analysts estimate the amount is minimal.

According to the Legislative Council's fiscal note for Proposition 135, any savings to Medicaid and government employee insurance from banning these procedures would be slight. This is because the surgeries are exceptionally rare. Colorado's three large pediatric surgical providers do not perform them on patients under 18.

While surgical costs for minors are not available, the Colorado Department of Health Care Policy and Financing reported that Medicaid spent about $1.1 million on hormone therapy for more than 500 minors in fiscal year 2024-2025. A federal rule taking effect in October 2026 blocks federal Medicaid funds for youth gender-affirming care, though states can still use their own money to cover it.

Supporters of Proposition 135 argue that taxpayer dollars and public health plans should never fund irreversible sex-altering procedures on minors, regardless of how often they occur. Opponents argue that these surgeries are already virtually non-existent for minors. They say the measure is an unnecessary government intrusion that could inadvertently ban medically necessary care for both transgender and non-transgender youth.

Yes, the measure's language could affect non-transgender minors seeking certain reconstructive procedures, depending on how medical providers and state regulators interpret the law.

According to the 2026 Legislative Council ballot information booklet, Proposition 135 does not list specific prohibited surgeries. Instead, it bans procedures based on the reason they are performed. It prohibits surgeries that alter biological sex characteristics if they are done in response to a minor's perception of sex or gender. The state's analysis notes this wording may limit surgeries for non-transgender minors if a provider interprets the treatment as responding to the patient's gender perception.

The measure does include specific exemptions. It allows male circumcision, treatments for medically verifiable disorders of sex development, and surgeries to correct acquired physical or chemical abnormalities.

Opponents, including the Colorado Medical Society, warn that banning surgeries based on a patient's motivation could disrupt broader pediatric healthcare beyond transgender care. Supporters argue the broad language is necessary to protect all minors from permanent, irreversible procedures they lack the maturity to consent to. They note the exemptions preserve access to medically necessary care for physical abnormalities and atypical development.