US State Policies on Gender Marker Changes and Fertility Preservation Coverage: Implications for Transgender and Gender-Diverse Health.

The ability to receive gender affirmation within legal and medical contexts has positive impacts on transgender and gender-diverse (TGD) population health. Yet, legal gender affirmation, which involves obtaining gender-concordant identity documents, remains restricted in several US states that require documentation of medical or surgical interventions. Meanwhile, some gender-affirming medical treatments can compromise long-term reproductive potential, leading to iatrogenic infertility; however, insurance coverage of fertility services for TGD individuals is limited. Inability to access fertility preservation services before gender-affirming medical care not only restricts reproductive autonomy but also compounds the harm of restrictive legal gender policies. This may leave individuals to choose between preserving their fertility and obtaining accurate legal documentation. Together, these intersecting policy barriers jeopardize TGD population health by undermining access to medically necessary health care, violating reproductive freedom, and limiting full participation in civil society without violence and discrimination. This article examines the population health implications of these burdens, evaluates the current US state policy landscape, and explores potential solutions. (Am J Public Health. 2026;116(10):1629-1638. https://doi.org/10.2105/AJPH.2025.308380).