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ST. LOUIS COUNTY — Back in third grade, when Max was introduced to his classmates as the person he really was — a boy — many of his teachers, neighbors and friends didn’t know what the word transgender meant.

But they knew Max: smart, kind and capable. So they embraced him. Now, 17-year-old Max is half a lifetime removed from his social transition, wrapping up his junior year of high school and thinking about his place in the bigger world.

“I am really lucky,� he said. “There wasn’t ever a time where I didn’t feel supported.�

It’s been nearly a decade since Max, who is using a pseudonym to protect his privacy, made his social transition. In that time, the estimated 1.4 million transgender people in the United States have gained visibility, and, in many cases, broader acceptance. A spate of television shows and movies have centered around transgender characters. Olympian Caitlyn Jenner announced herself on the cover of Vanity Fair. And a transgender contestant dominated on “Jeopardy!� last fall.

Changes have also come in smaller, more everyday ways. People include their preferred pronouns in email signatures and Twitter bios. Gender-inclusive clothing lines are sold at stores from Nordstrom to Target. Youth organizations, such as the Boy Scouts, have modified their policies to include all children, regardless of their gender identity.

Max has grown up largely free from the pinch of prejudice, focusing on the same things as his classmates: grades and socializing, enduring braces, earning a driver’s license. So far, no opportunities have been off limits to him.

“He can get into whatever spaces he wants,� his mom said.

Max has a tight band of friends, many of whom he’s known since kindergarten. Any whiff of intolerance has been quickly intercepted and snuffed out by a protective sister. Mostly, his gender identity goes unnoticed. He’s not even sure who at his school knows he’s trans.

But Max and his family do have worries. Most come from far beyond their suburban ÃÛÑ¿´«Ã½ bubble.

aiming to limit the rights of LGBTQ Americans have been introduced in state legislatures this year, according to the Human Rights Campaign, an advocacy organization based in Washington. Arkansas, Arizona and Texas have passed laws banning gender-affirming medical treatment for children. More than a dozen states restrict transgender women and girls from playing on female sports teams in public schools.

The Republican-led Missouri Legislature is following the same path. At least half a dozen measures were introduced this session, continuing a pattern that has emerged over the past few years.

Late last month, the House approved a bill that limits transgender athletes to teams that match the gender listed on their birth certificate. It also OK’d a measure allowing school districts to vote on whether to enact sports bans.

“There’s always pushback whenever there’s progress,� said Rebecca Zingarelli of Ballwin. Her 12-year-old transgender daughter has had only positive experiences since she announced she wanted to “come out to the world immediately� almost two years ago. Middle school has been a joy.

But the Zingarelli family is preparing to move out of state this summer, a decision influenced by the uncertainty that their daughter will continue to flourish if she stays here.

“The last legislative session was really rough,� said Zingarelli. “That emotional weight was really overwhelming.�

The thought of spending months out of each year anxiously monitoring the Missouri Capitol was too much. Moving seems easier.

Access to sports

Sen. Mike Moon, R-Ash Grove, is the sponsor of two bills, one on sports and the other on health care, that have passed out of committee this spring.

The first, the , would withhold funding from public schools that allow transgender girls or women to play on female teams, from middle school through college.

Moon, whose district comprises the southwest corner of Missouri, said he proposed the bill after hearing concerns from his constituents that transgender girls would have an advantage, though he did not know of any specific teams that have been affected.

“They believe it’s just fairness for their children,� Moon said.

In March, University of Pennsylvania swimmer Lia Thomas kicked up controversy when she became the first transgender athlete to win an NCAA title.

Thomas is an extreme example, the bill’s opponents say. Most girls just want to play with their friends.

“There are many threats to women and women’s sports,â€� said Katy Erker-Lynch, executive director of , a statewide nonprofit based in ÃÛÑ¿´«Ã½ that advocates for LGBTQ rights. “Transgender athletes are not one of those things.â€�

She questioned how such a law would be enforced: “Will there be genital inspections of children?�

Moon said that if parents found out a transgender child was playing, he assumed they would approach their school board first, to avert any financial losses.

“What we are trying to do is provide an equal playing field for young women and have a fair competition,� he said. “We have other options through coed sports.�

The Missouri State High School Activities Association issued more than a decade ago. Since then, seven trans athletes — two boys and five girls — have applied to play, a spokesman for the association said; all have been approved. Transgender girls are required to have been receiving hormone therapy for a year before they can play for a girls team; transgender boys do not have a waiting period.

Max, who has always loved sports, has not faced scrutiny over his participation. But he has streamlined as he’s gotten older, dropping team sports like soccer and football in favor of swimming and running. He logs up to 40 miles a week, jogging through his neighborhood and cranking out laps at the high school track.

Some days, the motivation comes more easily than others. “I have a love-hate relationship with running,� Max likes to joke.

Access to care

Moon’s other bill, the one with more substantial repercussions, would restrict health care for transgender youths.

Prepubescent children do not receive medical interventions, but once puberty sets in, , which pause the physical changes of growing up. By their mid-teens, they may choose to begin a , with transgender girls receiving estrogen and transgender boys, testosterone.

None of those interventions happen unless the child has undergone psychological and physical exams and received a letter of support from a mental-health provider. Hormone levels determine secondary sex characteristics, so transgender girls develop breasts and wider hips; transgender boys, facial hair and a deeper voice. Some, but not all, of the changes are reversible if the patient goes off hormones.

For Max’s mother, the most difficult phase was when Max was in early puberty. She could see the distress in her normally laid-back son that his body would become like his sister’s.

“It was very painful,� his mom said.

It took a few months of doctor visits and jumping through insurance hoops to access the blockers. Shots came first, then an implant. The implant, which cost more than $4,000, did double duty: considered a surgical procedure, it allowed Max to have his birth certificate changed to male.

Major medical organizations, such as the American Academy of Pediatrics and the Endocrine Society, endorse puberty blockers and hormone treatments as . They say the mental health ramifications of not addressing the needs of such patients put them in peril.

More than half of transgender teens have considered suicide, according to , an LGBTQ crisis-intervention nonprofit. A study released in February by the found that receiving gender-affirming care lowers the risk of depression and suicide for transgender teens.

Moon’s bill, named the would prohibit such treatment and revoke the medical licenses of anyone who provides it. Supporters of the bill say teenagers are not capable of making choices with potential long-term effects.

“The primary intent is to protect the children,� said Moon. “When they are old enough to make those decisions for themselves, they can.�

Health practitioners and parents dispute that idea. A person’s awareness of being a boy or a girl happens in the first year of life, and gender issues can emerge as early as preschool, said Patricia Berne, a psychologist based in Clayton. Berne has been in practice for more than four decades. Early on, her transgender patients were all adults.

“There was the belief that children couldn’t know,� she said. “But when you talked to them, you always found out that, very early, they knew.�

The medical community began acknowledging that phenomenon about 25 years ago, said Berne. In 2007, a transgender clinic in Boston opened; it was the first of its kind in the United States. Since then, more therapists have specialized in gender issues, and LGBTQ topics have been integrated into medical schools’ curricula.

‘Autonomy and dignity’

Social resources are also more accessible. , based in ÃÛÑ¿´«Ã½, was formed in 2011 by four sets of parents of transgender children. The support group now has branches in 15 states; half of its chapters have been added in the past two years.

“We are all living similar experiences,â€� said Susan Halla of ÃÛÑ¿´«Ã½, president of TransParent’s board. “But we have different stories and come in with different levels of understanding.â€�

TransParent’s primary mission is to connect parents and provide information, but in recent years, the nonprofit has extended its focus to include legislative advocacy.

Christopher Lewis, a pediatric endocrinologist with Washington University, co-founded the almost five years ago. Doctors there see 250 new patients a year. Some of that increase is due to a greater understanding of transgender care, he said, and broader insurance coverage. But many families — especially in rural areas — still have difficulty finding doctors with experience treating children with gender dysphoria.

If the “Save Adolescents� act becomes law, treatment will be impossible to access throughout the state. Lewis travels to Jefferson City regularly to speak against medical prohibitions. He canceled 17 appointments on a Tuesday in March to testify in front of lawmakers when Moon’s bill was read.

“We are taking away the autonomy and dignity of these patients and families … ,� he told lawmakers. “It will limit access to care that we know benefits them. It’s only going to harm them.�

Misconceptions about treatment can color people’s opinions, Lewis said. No one younger than 18 undergoes gender-affirming surgery — and many transgender adults never have surgery. Patients are monitored regularly by a team of specialists who keep a close eye on hormone levels and potential side effects, such as blood clots and bone-density loss.

The incidence of regret is small, said Lewis, and is almost always attributed to social consequences: lack of family acceptance, job loss or victimization.

Sleepless nights

For many families, having a transgender child is about as disruptive as having one who is left-handed. It’s one characteristic among many.

Daniel Bogard’s 8-year-old loves learning about outer space, playing basketball and strumming on his ukulele. He’s also transgender.

From the time he was 3, he would ask for “boy� clothes and a short haircut. In March 2020, during a kindergarten Zoom lesson, he announced his new name and pronouns. A year later, his teacher and classmates threw him a party to celebrate the anniversary of his social transition.

“It’s been so uneventful in our lives,� Bogard said about the process. But it’s a different story outside of his community.

Bogard has worn a path from his ÃÛÑ¿´«Ã½ County home — the one his grandparents built and he grew up in — to Jefferson City, lobbying with dozens of others to show legislators that their children need the same things as all children: love, support and acceptance.

Sometimes, he brings along his 8-year-old, to “make him seem human.� The lawmakers they have met seem receptive, even empathetic, Bogard said. But that’s no assurance.

Ruminating on what his family will do if the medical prohibition passes keeps Bogard up at night.

“The impact of it on me has been pretty brutal. I literally wake up thinking the government is here for my kids,� he said. “All families of transgender kids are thinking ahead to what will happen, what will we do if these bills become law.�

For the Bogards, it will likely mean a move out of the home four generations of their family have lived in — and away from their beloved school, jobs and neighbors — to Illinois.

Max’s family has been fortunate with timing. In several months, Max will be an adult. He will still have to wrestle with knowing who to share his story with, and when. He — like all transgender folks — will be at a greater risk of violence. And in many places, including Missouri, he won’t have protections against job discrimination.

But he won’t have to worry about access to treatment. His extracurricular activities won’t be curtailed.

Max, though, isn’t planning on sticking around. This summer could be his last one at home. He’s considering college on the East Coast and, after that, working in foreign affairs far from the Midwest — maybe even overseas.

Being transgender isn’t the only factor pushing Max out of the Show-Me State, but “it’s definitely a reason not to stay,� he said.

A map of the United States hangs in his bedroom. He uses it to track his travels on summer vacations and family road trips. When he visits a new state — “you have to spend the night there for it to count,� he said — he scratches off the foil cover.

Underneath, Maine has turned orange. Vermont is green; New York, gold; Massachusetts, indigo.

He’s not sure where exactly he’ll end up. But he sees his future in the rainbow.