Introduction
Activity in state legislative sessions in the first quarter of 2024 has demonstrated what advocates for sexual and reproductive health and rights have long known to be true: policymakers opposed to reproductive freedom will not stop at banning and restricting abortion. For years, their major focus was on overturning Roe v. Wade; however, their ultimate goals include dismantling other facets of sexual and reproductive health and rights—such as access to contraception, assisted reproductive technologies and gender-affirming care.
The landscape of abortion access in the United States is fractured: Fourteen states enforce total abortion bans, and seven more restrict access at gestational durations that would have been unconstitutional under Roe. At this point in the second full legislative sessions since the US Supreme Court overturned Roe, state legislative trends indicate that these evolving and growing attacks on sexual and reproductive health and rights are following several distinct patterns. For example, attacks on in vitro fertilization (IVF) have exemplified the push toward enshrining fetal and embryonic legal rights in state law in order to restrict various forms of reproductive health care.
Additionally, many of the restrictive trends during this legislative session target young people's access to sexual and reproductive health care—particularly access to abortion, contraception and gender-affirming care—as well as access to comprehensive sex education. These attacks not only harm young people; they can also serve as precursors to more ambitious attacks on sexual and reproductive health care in general.
Continuing Restrictions on Abortion Access
Abortion bans
This legislative session has coincided with state court decisions that have had a major impact on abortion access in key states, most notably in Florida and Arizona. Since the US Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision in June 2022, Florida has become a key access point in the region for abortion care. Guttmacher’s Monthly Abortion Provision Study data demonstrated a major increase in out-of-state patients receiving care in Florida: 3,700 more patients from other states obtained an abortion in Florida in the first half of 2023 than in a similar period in 2020. However, on April 1, 2024, the Florida Supreme Court affirmed the constitutionality of the state’s ban on abortion at 15 weeks of pregnancy, which ushered in the ability to enforce a six-week ban passed by the state legislature that had been on hold while litigation continued. The six-week ban went into effect on May 1. Additionally, the state supreme court approved a ballot initiative for the November election that would establish state constitutional protection of abortion up to fetal viability or to protect the patient’s health. Although the ballot initiative opens the door for a potential change in abortion access if it passes, the reality is that many individuals in Florida, and throughout the region, will be denied abortion care for at least several months.
On April 9, the Arizona Supreme Court upheld a 160-year-old state law that would ban abortion completely with very limited exceptions. Abortion is already banned at 15 weeks of pregnancy and heavily restricted in the state. After the total ban was upheld, the state legislature passed a bill to repeal it and the governor signed the bill. This legislation only repeals the total abortion ban; the 15-week ban will stay in place. There may still be a 90-day period after the end of the state’s legislative session before the repeal can go into effect and the total ban may take effect during that time. While the situation continues to develop, any period of time without abortion access will cause harm to Arizona residents. Arizona borders Colorado and New Mexico, two states that already had large increases in out-of-state abortion patients in the first half of 2023 compared with a similar time frame in 2020. While clinics in these two states have been able to provide care for the expanded patient caseload so far, a total abortion ban taking effect in Arizona would further increase this demand. Efforts are underway to present a ballot initiative in November that would add a right to abortion until fetal viability to the Arizona state constitution, with exceptions to any restrictions after that point to protect the patient’s physical or mental health.
Funding for anti-abortion centers
One of the anti-abortion trends in state legislatures this session has been providing government funding for anti-abortion centers, also known as crisis pregnancy centers. These are fake reproductive health clinics that purport to help pregnant people while providing mis- and disinformation in order to dissuade people from seeking an abortion. Some states have been funding such organizations for years, with states such as Florida and Ohio increasing their funding by tens of thousands of dollars in recent years. The funds come through direct grants or state programs labeled “alternatives to abortion," and sometimes use federal funding from the Temporary Assistance for Needy Families program to do so. This legislative session, 12 states have introduced bills to provide funding to anti-abortion centers, allocating between $200,000 and nearly $30 million to these harmful organizations. Often introduced in states that severely restrict abortion access, these bills face little opposition and are likely to succeed. Two of these bills, both in Utah, have been signed into law so far in 2024.
Attempts to Establish Fetal and Embryonic Personhood
Compounding the explicit attacks on abortion are growing efforts to establish the legal rights of a person for embryos or fetuses. The radical concept of fetal and embryonic “personhood” has long been championed by the anti-abortion movement. Those opposed to sexual and reproductive health and rights seek to make it impossible for individuals to make their own reproductive decisions, as these efforts can impact access to and the legality of abortion, contraception and assisted reproductive technologies, such as IVF. Granting fetal rights would also lead to the criminalization of pregnancy outcomes, exerting even greater state control over pregnant individuals. While personhood efforts have gained greater attention in early 2024, the concept has been a part of the anti-reproductive freedom movement for decades and has been presented in various types of legislation. Since the Dobbs decision and the large flurry of abortion bans and restrictions immediately following it, personhood efforts have come into greater focus.
In February, the Alabama Supreme Court ruled in an unprecedented decision that embryos created through IVF are considered children under the state’s Wrongful Death of a Minor law. Providers and patients alike were unsure of the consequences and implications of the ruling, causing many clinics to halt IVF care entirely. This was not only catastrophic for those pursuing assisted reproduction in Alabama, but also sent a nationwide message about how far the anti-abortion movement is willing and able to go to restrict reproductive health services. The response was a rush to protect IVF patients and providers, and a number of states took immediate action. Ten states, including Alabama, introduced bills that either explicitly protect providers from criminal or civil liability or clarify that fertilized embryos outside of a human body are not human beings; the majority of these states severely restrict or entirely ban abortion. Despite these efforts, the IVF landscape remains messy—even with Alabama’s new protective law in effect, certain clinics are terminating their services in anticipation of ongoing litigation and legal confusion.
Attacks on Young People’s Reproductive Autonomy
Another evolving area of attacks on reproductive freedom is the passage of restrictions on young people’s access to sexual and reproductive health services and education. Historically these restrictions have taken the form of policies like parental consent requirements for abortion and age-based limits on the ability to consent to family planning services. These restrictive policies are often depicted as being reasonable measures aimed at a population that is not mature enough to make decisions regarding their own care. This rationale makes passing restrictions on young people’s care relatively easier than passing restrictions that affect adults. Once an emerging trend, policies like parental consent or notification requirements for abortion care are now in place in 36 states. Targeting young people’s care has continued in the 2024 state legislative sessions, but has begun to present in new ways in this post-Roe environment.
Attacks on young people’s abortion access
One new type of restriction is legislation that seeks to assign civil or criminal liability to adults who help a minor obtain abortion care. One such ban on abortion support was enacted in Idaho in 2023 but blocked by a federal judge as litigation proceeds. The plaintiffs in the lawsuit are all groups or individuals who often assist people, including minors, access the abortion care they need. Four states introduced bills this session that are nearly identical to the Idaho law—Alabama, Mississippi, Oklahoma and Tennessee —although the Mississippi legislation is no longer in play. The Tennessee legislation was passed by the legislature and sent to the governor’s desk on April 29. As more and more individuals need to travel to obtain abortion care because of abortion bans and restrictions in their home state, this growing trend seeks to make it more difficult for young people to get the care they need by threatening individuals who help them do so.
Restricting contraceptive access for young people
Another targeted attack on youth access to reproductive health care is restricting access to contraceptive services, which compromises young people’s rights to confidentiality and autonomy. In a recent decision on a Texas case, the 5th Circuit Court of Appeals upheld a lower court ruling in March that blocked clinics in Texas that receive federal Title X funding from providing prescription contraceptives to minors without parental consent. Like the other efforts at restricting youth access, decisions like this seek to impose additional, evolving restrictions on minors’ access to care and erode young people’s ability to make the decisions that are right for them. So far this session, there have been six bills introduced in four states that would require either parental notification or consent when young people try to access contraceptives in various circumstances. Just like parental notification and consent for abortion care slowly became normalized, this legislative activity demonstrates that similar efforts are underway for contraception.
Restricting sex education
More than 50 bills have been introduced across 28 states this year that would interfere with the ability of students to receive comprehensive sex education. Although many states began introducing sex and HIV education programs following the AIDS epidemic in the 1980s, these programs have faced consistent attacks, and today very few states meet the National Sex Education Standards. Sex education is not required in every state, and when provided, sex education is required to be medically accurate in only 20 states. Additionally, the majority of states require sex education curricula to emphasize abstinence.
Many of this year’s bills restrict the content that may be taught in schools, such as discussion of sexual orientation or gender identity, or restrict the ages at which students may receive sex or HIV education, or require a pseudo-scientific ultrasound video titled “Meet Baby Olivia” to be included in sex ed curricula. This video, which is not recommended as part of the National Sex Education Standards, is the product of the anti-abortion group Live Action and seeks to stigmatize abortion.
Continued attacks on gender-affirming care
In 2023, many states introduced and 19 enacted a wave of gender-affirming care bans targeting young people. Although these bans are harmful to trans youth and stigmatize health care, states have continued to introduce and pass these bills in 2024, and now nearly half of the states have enacted such bans. More than 35 bills have been introduced during this legislative session that would either restrict access to, or outright ban, gender-affirming care for young people—in addition to the more than 35 such bills that were carried over from last year’s legislative session. While the majority of these bans restrict care for people younger than 18, some would restrict care for people as old as 21. Three of these bills have been enacted so far this year (in Idaho, Ohio and Wyoming), as well as one executive order (in Ohio).
Twenty of the states that have enacted gender-affirming care bans also restrict abortion before 20 weeks of pregnancy, making it clear that many state legislators are anti-trans and anti-abortion, and both abortion bans and gender-affirming care bans come from the same playbook. Both types of bans seek to restrict bodily autonomy in medically unnecessary ways, rely on dis- and misinformation for support, and deepen existing inequalities for marginalized communities trying to access health care.
Response Tactics: Protecting Contraception
In the nearly two years since Roe was overturned, it has become increasingly clear that restrictions on abortion are the first step in dismantling access to reproductive autonomy entirely. The pursuit of this goal has been anything but subtle. For example, Supreme Court Justice Clarence Thomas outwardly called the right to contraception into question in the Dobbs decision, even though it has long been considered a fundamental aspect of health care. A number of states have made significant efforts to enshrine protections for contraception in the wake of these escalating threats. This session, more than 50 bills and proposed constitutional amendments that would codify the right to access contraceptives have been introduced in 27 states. Many of these protections include all reproductive health services. Currently, 10 states and the District of Columbia have laws explicitly protecting the right to contraception, and four states protect this right in their constitutions through the codification of reproductive freedom. Those working to safeguard reproductive rights in all states feel the urgency of the ever-changing anti-abortion narrative and its effects on other sexual and reproductive health care.
Conclusion
At the midway point of most 2024 state legislative sessions, some key trends have developed that warn of the growing and evolving efforts of those opposed to sexual and reproductive health and rights. Attacks on abortion have been further punctuated by efforts pushing the concept of fetal and embryonic “personhood,” implicating access to assisted reproductive technologies such as IVF. In addition, bills introduced in many state legislatures have followed familiar patterns of starting with and targeting youth access to sexual and reproductive health care. These trends underscore what we have long known—the movement opposed to reproductive freedom is not solely focused on abortion and it is not slowing down after the overturning of Roe.
