Policies related to transgender children and young adults, including sex-segregated school sports and gender transition medicine for minors, will be on the ballot in five states during the midterm elections.
Missourians and Coloradans will be asked to weigh whether to prohibit medical professionals from providing minors with procedures or treatments with the intent of transitioning their genders, including surgeries, puberty blockers, and cross-sex hormones.
Colorado voters will also join Nebraskans, Arizonans, and Washingtonians in deciding whether to restrict access to school-based sports based upon biological sex as confirmed by a healthcare professional or a sex-screening protocol, preventing biological males who identify as female from playing in women’s sports.
Since 2021, more than 25 states have adopted laws prohibiting students who identify as transgender from playing on school sports teams other than those matching their biological sex. Another 27 states have passed laws prohibiting or restricting access to transgender medical treatments for minors.
Terry Schilling, president of the American Principles Project, which lobbies against transgender medicine for minors and men in women’s sports, told the Washington Examiner that the ballot initiatives in these states are the result of “an organic, parent-led movement fighting back against the profit-driven insanity that has captured far too many institutions.”
“There are no red states or blue states when it comes to keeping men out of girls’ sports and locker rooms,” Schilling said. “These ballot initiatives show that parents are fed up with the $4.5 billion trans industrial complex that preys on vulnerable children.”
Here is where the ballot initiatives stand ahead of Election Day on Tuesday.
1. Missouri
Missouri’s Amendment 3 would repeal the abortion-rights amendment voters added to the state constitution in 2024, but it would also prohibit gender transition medical procedures for minors.
The amendment would prohibit minors in Missouri from receiving gender transition surgeries, defined as any “surgical procedure performed for the purpose of assisting an individual with identifying with and living as a gender different from his or her biological sex.” It would also prohibit cross-sex hormones and puberty blockers for the purpose of gender transition.
The Show Me State passed a law in 2023 preventing healthcare providers from performing gender transition medical procedures on minors, but the law is poised to sunset in August 2027. Passing the amendment would enshrine it in the constitution and eliminate the need for repassage in the legislature.
Gov. Mike Kehoe (R-MO) told the Washington Examiner that he and his wife have been active in rallying support for Amendment 3 not only to implement gestational age limits and tighter medical safety restrictions for abortion but also to prevent what he described as the “mutilation of minors.”
Kehoe said he is a staunch believer in life beginning at conception but that the transgender medical procedure prong of Amendment 3 is “a lot more black and white” for voters of different beliefs than the abortion issue.
“I think it is critically important that Missourians very much understand that when you’re under 18 years old, you don’t have the ability to make those types of body-changing decisions,” Kehoe said. “And we certainly think that should be something that is carved in our constitution.”
2. Colorado
Colorado voters will decide on ballot measures on transgender athletes and transgender surgeries for minors.
Proposition 134 would require schools and association-sponsored athletic teams to be categorized as male, female, or coeducational and would prohibit males from participating in female-designated sports. The initiative defines male and female based upon the production of sperm and ova, respectively.
Proposition 135 would prohibit healthcare professionals from performing invasive gender transition surgeries on minors for the purpose of altering their biological sex characteristics.
So-called “gender-affirming” surgeries range from mastectomies and genital surgeries to facial reconstruction and vocal cord alterations. The ballot initiative would not limit pharmacological gender transition treatments such as puberty-blocking drugs or cross-sex hormones.
Colorado is one of the 17 states plus the District of Columbia to have enacted a “shield law” that protects healthcare workers from criminal liability for providing transgender medical treatment to out-of-state residents who live in jurisdictions where it is illegal.
Current law in the state also allows school districts to request paperwork from healthcare providers to attest to a student’s sex before they are allowed to play on a sports team.
In May, the state legislature passed a sweeping bill on transgender issues, including making the refusal to use a transgender person’s chosen name a discriminatory act according to legal codes. Among other things, the bill also requires school policies to be “inclusive of all reasons” students might change their names.
3. Arizona
The formal name for Arizona’s Proposition 318 is the “Require All Schools and Athletic Associations to Restrict Sports Participation and Access to Private Spaces Based on Sex Measure.”
Arizonans voting on the measure will decide whether to prohibit school and athletic associations from authorizing any student, athlete, or employee from using a restroom, locker room, or other private space that is not designated for their biological sex.
Current Arizona law allows biological girls or females to participate on teams designated for boys or males but not the reverse. By contrast, Proposition 318 would require schools to designate K-12 sports teams as exclusively “male,” “female,” or “coeducational” based upon sex.
The measure defines sex as “biological status as male or female as recorded at birth on the individual’s original birth certificate” and would not require the student to be examined by a physician to attest to biological sex.
4. Nebraska
Voters in Nebraska will decide whether to enshrine sex-segregated sports into their state constitution with Measure 442, the Sex Requirement for School and College Sports Initiative.
If passed, the measure would create a constitutional amendment that requires schools to “designate each athletic team or sport” as either male, female, or coeducational.
Adding this language to the state constitution would fortify the law passed by the Nebraska Legislature in 2025 requiring all K-12 and collegiate sports to designate teams based on sex, which the law defines based on an athlete’s reproductive system.
The current law also requires that each student-athlete provide the school with a document from a physician confirming the student’s sex.
5. Washington
With Initiative 638, Washingtonians will be asked to vote on whether to require school districts and interscholastic sports associations to “prohibit biologically male students from competing with and against female students.”
Instead of relying on birth certificates to identify students as male or female, the initiative would require students who wish to participate on girls’ sports teams to provide a certification from a healthcare provider verifying the student’s biological sex based on her “reproductive anatomy, genetic makeup, or normal endogenously produced testosterone levels.”
Proponents of the measure argue it upholds the intent of the federal Title IX statute protecting women’s sports, but some opponents of the measure suggest that requiring a pelvic exam or genetic testing before playing a school sport is potentially both excessively costly and highly invasive.
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Professional women’s soccer player Megan Rapinoe, a Washington state native and supporter of transgender athletes, in July penned an opinion piece against the amendment, saying the exams to prove a student’s sex go too far.
“In a country rife with sexual assault, young girls would have to undergo invasive inspections of their genitals, or pay for a DNA or hormone test, as part of their school sports physicals,” Rapinoe wrote. “Doctors say genital inspections are not only medically unnecessary to play sports, they can traumatize and physically harm young girls.”