Nebraska will require transgender youth to wait seven days and undergo up to 18 weeks of therapy before pursuing gender-affirming healthcare treatments under new emergency regulations adopted by the state health department.

The regulations, which were posted on the state Health and Human Services department’s website but later removed, require transgender-identifying youth to undergo at least 40 hours of “gender-identity-focused” therapy that is “clinically neutral and not in a gender-affirming or conversion context” before receiving gender-affirming treatments.

The regulations require a patient’s parents or legal guardians to be involved in any treatment, including the 40 required hours of therapy. The therapy is ostensibly intended to ensure a therapist understands a patient’s needs, reports The Associated Press.

The regulations also require therapists to determine whether a patient’s distress is genuinely driven by their gender dysphoria or whether other unresolved mental or physical health conditions, such as autism or trauma from past sexual abuse, are influencing it. Patients must also undergo at least one hour of therapy every 90 days in order to evaluate the therapy’s “ongoing effects on a patient’s mental health.” 

They also require transgender youth to wait seven days before starting puberty blockers or hormone therapy.

But that seven-day waiting period cannot start until a doctor receives a signed consent form from a parent or legal guardian — or the minor themselves, if they are emancipated.

The waiting period is intended to give patients and their families “enough time to weigh the risks and benefits of treatment.”

Other requirements mandate that transgender youth must have been fully out and living as their gender for six months prior to treatment, require a minor’s parents to be the only ones who can collect their prescription, which must be labeled for gender dysphoria, and require youth and their parents to be presented medical forms that declare gender-affirming care to be risky and encourage patients to pursue “alternatives” to care.

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The new regulations will remain in effect while the department hears public comment on a permanent set of rules.

The department intends to release a proposed final version by the end of October, with a public hearing in Lincoln, the state capital, on November 28.

The regulations drop just as Nebraska’s law prohibiting transgender individuals under 19 — who are considered minors under state law — from undergoing gender-affirming surgical treatments takes effect.

The law, signed earlier this year by Republican Gov. Jim Pillen, also puts the state’s chief medical officer — a political appointee — in charge of setting rules for when and how trans-identifying minors may access hormonal interventions.

During the signing ceremony, Pillen suggested that children who believe they are born in the wrong body and their parents who consent to gender-affirming care are being “duped.”

“That is absolutely Lucifer at its finest,” Pillen said.

Critics of the new regulations had previously accused the department of slow-walking the release of the regulations to further delay transgender youth from pursuing a gender transition. A spokesperson for the health department rejected that assertion, according to The AP.

Journalist and transgender advocate Erin Reed criticized some of the regulations on her Substack, arguing that the forms claiming gender-affirming care is experimental or dangerous are misleading and filled with misinformation.

She also argued that requiring therapists not to “affirm” a child’s gender identity would effectively force them to misgender the patient for weeks before care could be pursued.

“Collectively, these guidelines champion a new form of conversion therapy dubbed ‘Gender Exploratory Therapy,'” Reed wrote. “Despite its innocuous name, this therapy seeks to explore all possible causes for a transgender person to experience gender dysphoria other than genuine transness.

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“It’s important to highlight that the patient being transgender is never deemed an acceptable conclusion,” she continued. “Treatments are perpetually dangled just beyond reach until the trans youth believes they are not actually transgender, that too much time has elapsed and puberty has induced too many changes for a successful transition, or they turn 18 and age out of care.

“Mirroring crisis pregnancy centers, these tactics are deployed under the pretense of ‘alternative care’ and ‘neutral treatment,’ despite the deception inherent in the care provided.”

Grant Friedman, a legal fellow for the American Civil Liberties Union of Nebraska, argued that decisions about whether to pursue gender-affirming care should be left to patients, their parents, and medical providers. He also criticized the 18 weeks of therapy requirement, noting that a dearth of mental health practitioners in the state would effectively prolong patients’ dysphoria by requiring them to surmount additional obstacles to gender-affirming treatments. 

“It just adds an additional barrier to existing care barriers that already exist in our health care system,” he said.

Further complicating the matter is a new development in which, according to some transgender allies, pharmacists throughout the state are refusing to fill prescriptions for gender-affirming treatments like hormones — even when parents are abiding by the department’s rules.

The law does contain an exception for minors who started treatment prior to the law’s passage, allowing them to continue receiving care, but some parents report difficulty getting pharmacists to comply with their requests. 

While gender confirmation surgeries are rarely performed on minors, nearly every major medical organization in the United States has said that puberty blockers and hormone therapy are the recommended treatments for minors suffering from gender dysphoria.

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The American Academy of Pediatrics says that gender-affirming care for minors can help reduce the risk of suicide among trans-identifying youth.

Nebraska is one of 22 states that have passed laws restricting some form of gender-affirming medical care for transgender minors.

Federal judges have sought to block some of those laws, only to have their injunctions overturned by conservative appeals courts, including the 6th Circuit and 11th Circuit.

In June, a federal judge found a nearly identical ban in Arkansas to be unconstitutional. That decision is being appealed to the 8th U.S. Circuit Court of Appeals, which also handles cases from Nebraska.