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# Proposition 135 - Prohibit Surgery on Minors in Response to Perception of Sex or Gender
- URL: https://www.thecoloradoconservative.com/proposition-135-prohibit-surgery-on-minors-in-response-to-perception-of-sex-or-gender/
- Published: 2026-09-21T00:09:17.000Z
- Updated: 2026-09-21T00:09:17.000Z
- Author: Eric Phelan

# OFFICIAL BALLOT QUESTION

*“Shall there be a change to the Colorado Revised Statutes modifying existing law by prohibiting surgery on a minor for the purpose of altering the minor’s biological sex characteristics, and, in connection therewith, prohibiting any health-care professional or other person from knowingly performing, prescribing, administering, or providing any surgery to a minor for the purpose of altering the minor’s biological sex characteristics and prohibiting the use of state or federal funds, Medicaid reimbursement, or insurance coverage to pay for this type of surgery?”*

**Source Colorado Secretary of State certified ballot title for Initiative 110**

# NEUTRAL OVERVIEW

Proposition 135 is a statutory measure prohibiting surgery on a person under 18 when the purpose is to alter biological sex characteristics as treatment in response to the minor’s perception of sex or gender. It also prohibits state or federal funds, Medicaid reimbursement, and insurance coverage from paying for prohibited surgery. A YES vote adopts the prohibition. A NO vote keeps current Colorado law, under which medically necessary surgery may be covered by public or private insurance or paid for out of pocket.

The measure does not prohibit all gender-related care. It does not restrict counseling or social transition, and its text does not prohibit puberty blockers or hormone therapy. It allows male circumcision and treatment for medically verifiable differences of sex development or acquired physical or chemical abnormalities. It takes effect January 1, 2027, and applies to violations on or after that date.

| **Policy**        | **Current approach**                                                                            | **Proposition 135**                                                                                                                             |
| ----------------- | ----------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------- |
| Covered treatment | Colorado protects access to medically necessary gender- and sex-based surgery                   | Prohibits surgery on a minor when its purpose is to alter biological sex characteristics in response to the minor’s perception of sex or gender |
| Age               | Care may be provided before age 18 under existing law and medical practice                      | The prohibition applies to every person under age 18                                                                                            |
| Exceptions        | Medical decisions follow existing standards and coverage rules                                  | Allows male circumcision and treatment for medically verifiable differences of sex development or acquired physical or chemical abnormalities   |
| Non-surgical care | Governed by existing law and medical standards                                                  | Not prohibited; counseling and social transition remain available, and the text does not ban puberty blockers or hormone therapy                |
| Payment           | Public programs, private insurance, or out-of-pocket payment may cover medically necessary care | Bars state or federal funds, Medicaid reimbursement, and insurance coverage for prohibited surgery                                              |
| Effective date    | Existing law remains in force                                                                   | January 1, 2027, for violations on or after that date                                                                                           |

**Source 2026 Colorado Blue Book analysis of Proposition 135 and final text of Initiative 110**

*The measure does not list specific procedures. Coverage depends on the purpose for which a surgery is performed. The official analysis therefore says the measure could affect some surgeries involving non-transgender minors if a provider, regulator, or insurer interprets the treatment as responding to the minor’s perception of sex or gender.*

The official analysis reports that surgery of this kind is rare among minors. A study of 2019 insurance claims estimated 2.1 surgeries per 100,000 transgender or gender-diverse youths ages 15 to 17, 0.1 per 100,000 ages 13 to 14, and none among children 12 and younger. Children’s Hospital Colorado, Rocky Mountain Children’s, and Denver Health report that they do not perform gender- or sex-based surgery on transgender patients under 18\. Colorado-specific totals for all procedures that the measure might prohibit are unknown.

# THE PROPONENT CASE

Supporters argue that irreversible surgery requires a level of maturity and long-term judgment that the law should not presume before adulthood. Adolescence includes rapid physical, emotional, and social development. A young person may be sincere and thoughtful while still lacking an adult’s experience of changing identity, relationships, health, and future goals. Waiting preserves every adult option; surgery can permanently remove options before that development is complete.

Supporters also argue that parents, clinicians, peers, schools, online communities, and cultural expectations can influence any adolescent’s decisions. They do not need to prove that every transgender identity is temporary or externally caused to justify a bright line for irreversible surgery. They contend that compassionate counseling and other non-surgical support can continue until the person is legally able to make the final decision as an adult.

# THE OPPONENT CASE

Opponents argue that gender dysphoria can be severe and that medical decisions should remain individualized among the patient, parents, and qualified clinicians. They note that the covered surgeries are already rare, that major Colorado pediatric providers report none for transgender patients under 18, and that a statewide prohibition may replace careful case review with a political rule. Some families may travel out of state or lose insurance coverage for care recommended by their medical team.

Opponents also warn that the measure is written around a surgery’s purpose rather than a defined list of procedures. That may create uncertainty for doctors and insurers and could delay reconstructive, corrective, or other medically necessary care for transgender or non-transgender minors. They fear that the law may deepen stigma or distress if young people hear it as a declaration that their identity is false or undeserving of care.

# OFFICIAL MEASURE INFORMATION

| **Item**                   | **Official listing**                                                                             |
| -------------------------- | ------------------------------------------------------------------------------------------------ |
| Approval required          | Majority vote because the measure changes Colorado statutes                                      |
| Effective date             | January 1, 2027                                                                                  |
| Designated representatives | Erin Lee and Michelle Austin                                                                     |
| Registered in support      | Protect Kids Colorado; Protect Our Children                                                      |
| Registered in opposition   | The People’s No; Families not Politics; No on 109 and 110; Protect Trans Kids; Vote Common Sense |

*Current committee listings and contact information: coloradosos.gov/pubs/elections/Initiatives/ballot/contacts/2026.html.*

**THE COLORADO CONSERVATIVE RECOMMENDS YES**

# WHY WE RECOMMEND YES

We recommend YES because irreversible surgery should wait until adulthood. That judgment does not require us to deny what a young person feels, dismiss a family’s concern, or treat transgender people as a problem to be solved. A person who feels estranged from his or her body deserves to be heard, treated with dignity, and given competent care. Adults should generally remain free to make informed decisions about their own bodies, including decisions others would not make for themselves.

The line is different for children because childhood is a protected period of development. Puberty can be confusing even when a young person has no conflict about sex or gender. Bodies change quickly. Emotions and self-understanding can change as well. Adolescents can reason carefully, but their ability to weigh permanent consequences, resist social pressure, and imagine a distant adult life is still developing. That is why the law draws age boundaries around many decisions that carry lasting consequences.

This does not mean every transgender adolescent is confused, manipulated, or destined to change identity. It would be unfair and unsupported to make that claim. It means only that neither the child, the family, the clinician, nor the state can know every future consequence with certainty. When the proposed intervention removes or permanently alters healthy sexual anatomy, uncertainty should favor time. Waiting preserves the person’s power to decide later; surgery cannot preserve the option to return to the body that existed before it.

Young people also live within strong networks of influence. Family expectations, peers, online communities, school culture, fear of rejection, and the desire to belong can shape any teenager’s choices. Influence can push in opposite directions. Some children may be pressured toward transition; others may be pressured to deny persistent distress. Good policy should protect them from both forms of coercion. A surgical age boundary does that only if Colorado also protects honest counseling, family communication, mental-health care, and freedom from bullying.

The official facts should keep this debate proportionate. These surgeries are rare among minors, and Colorado’s three large pediatric surgical providers report that they do not perform them on transgender patients under 18\. Proposition 135 is therefore mainly a prospective boundary, not an emergency response to a common procedure. We support it because a rare irreversible act can still justify a clear rule, but supporters should not exaggerate its frequency or portray transgender families as reckless.

The measure is also narrower than much of the public debate. It prohibits surgery for a specified purpose. It does not ban counseling, social transition, puberty blockers, or hormone therapy. Voters are not being asked to resolve every dispute over gender-related medicine. They are being asked whether surgery that alters a minor’s biological sex characteristics should wait until age 18\. Keeping that question narrow is essential to an honest YES recommendation.

The strongest objection is parental and medical authority. Conservatives ordinarily resist replacing families and physicians with a statewide command. Parents have the primary duty to care for their children, and clinicians must consider circumstances that statutes cannot anticipate. We give that objection real weight. Yet parental permission does not settle every question involving an irreversible intervention on a child. The state already sets outer limits where the potential loss cannot later be restored. We believe this is one of those limited cases.

A second objection concerns mental health. A young person denied a requested surgery may experience the delay as rejection, especially when gender dysphoria is severe. Colorado must not enact the prohibition and then abandon the child. Schools, families, clinicians, and communities should provide respectful counseling, crisis care, protection from harassment, and space for the young person to speak without being pushed toward a predetermined conclusion. No child should be told that dignity depends on surgery, and no child should be told that distress is imaginary.

The measure’s drafting creates a separate problem. It prohibits surgery based on the purpose of treatment rather than naming procedures. The official analysis warns that this could affect non-transgender minors if an insurer or regulator interprets a surgery as responding to sex or gender perception. The General Assembly and regulators should apply the law narrowly, protect treatment for injury, disease, congenital conditions, reconstruction, and acquired abnormalities, and create prompt confidential review when coverage is disputed. Insurers must not use the measure as a pretext to deny unrelated care.

Enforcement should focus on providers and payers, not on children or families. Minors should face no criminal liability, public investigation, loss of unrelated health care, or disclosure of private medical records. Professional discipline should require proof that a person knowingly provided a prohibited surgery for the defined purpose. Emergency and medically necessary care outside that purpose must remain available without delay.

Proposition 135 is statutory, so lawmakers can correct overbreadth, enforcement gaps, or harmful unintended effects without another constitutional amendment. That matters to our recommendation. If implementation blocks ordinary reconstructive care, drives denials beyond the text, or leaves vulnerable children without support, the legislature should amend the law. Protecting children includes preserving future choice and responding honestly when a rule causes harm.

The humane position is neither forced affirmation nor forced denial. It is to take a child’s words seriously, protect the child from coercion, provide care, and reserve irreversible surgery for the adult that child will become. Waiting is not a verdict on who someone is. It preserves the person’s authority to decide who to be after childhood and puberty are behind them. For that reason, while insisting on narrow enforcement and continuing support, The Colorado Conservative recommends a YES vote.

# HOW WE REACHED THE SCORES

Each category uses five tests worth 0 to 10 points. The fixed anchors are: 0 for clear harm or failure; 2 for a material weakness; 5 for mixed or neutral evidence; 8 for a clear benefit with workable safeguards; and 10 for an exceptional benefit with strong controls. Intermediate whole numbers are used only when the evidence falls between anchors.

Star conversion is fixed: 0–4 points earns no star; 5–14 earns one; 15–24 earns two; 25–34 earns three; 35–44 earns four; and 45–50 earns five. The same thresholds apply to every category.

| **Category**              | **Points** | **Stars** |
| ------------------------- | ---------- | --------- |
| Fiscal Responsibility     | 37/50      | ★★★★☆     |
| Limited Government        | 24/50      | ★★☆☆☆     |
| Individual Liberty        | 30/50      | ★★★☆☆     |
| Institutional Integrity   | 28/50      | ★★★☆☆     |
| Long-Term Colorado Impact | 35/50      | ★★★★☆     |

**FISCAL RESPONSIBILITY 37 OF 50 ★★★★☆**

*The measure creates a small administrative burden and may produce minimal savings, though litigation and disputed coverage could add costs.*

| **Test**                | **Pts** | **Evidence and reason**                                                                                                            |
| ----------------------- | ------- | ---------------------------------------------------------------------------------------------------------------------------------- |
| Administrative workload | 8       | DORA and public health employers must update rules, policies, and materials, but the official analysis expects minimal costs.      |
| Public program savings  | 6       | Medicaid and public employee plans may save money on prohibited surgery, but the official estimate says savings should be minimal. |
| Litigation exposure     | 4       | Purpose-based coverage and challenges under existing law may increase state and local legal expenses.                              |
| Program footprint       | 10      | The measure creates no new benefit, agency, facility, grant program, or large permanent bureaucracy.                               |
| Funding rule clarity    | 9       | It clearly bars public funds, Medicaid reimbursement, and insurance coverage for surgery prohibited by the measure.                |
| Metric total            | 37      | ★★★★☆                                                                                                                              |

**LIMITED GOVERNMENT 24 OF 50 ★★☆☆☆**

*A narrow child-protection boundary can be legitimate, but this measure overrides family, physician, and insurance decisions statewide.*

| **Test**                        | **Pts** | **Evidence and reason**                                                                                                    |
| ------------------------------- | ------- | -------------------------------------------------------------------------------------------------------------------------- |
| Child-protection role           | 9       | Government has a legitimate duty to place outer limits on irreversible interventions involving minors.                     |
| Parental and medical discretion | 3       | The categorical rule applies even when a minor, parents, and clinicians agree that surgery is medically appropriate.       |
| Scope tailoring                 | 4       | The ban is tied to purpose rather than a defined list of procedures, increasing the risk of reaching unintended care.      |
| Private contract freedom        | 2       | The measure prevents private insurance from covering prohibited surgery, extending beyond control of public funds.         |
| Statutory reversibility         | 6       | The General Assembly may revise the statute, but changing a voter-approved law still carries political and legal friction. |
| Metric total                    | 24      | ★★☆☆☆                                                                                                                      |

**INDIVIDUAL LIBERTY 30 OF 50 ★★★☆☆**

*The measure preserves a person’s future choice while limiting the present choices of minors, parents, clinicians, and insured families.*

| **Test**                    | **Pts** | **Evidence and reason**                                                                                                           |
| --------------------------- | ------- | --------------------------------------------------------------------------------------------------------------------------------- |
| Future bodily autonomy      | 10      | Waiting until adulthood preserves the individual’s ability to choose surgery later and avoids an irreversible childhood decision. |
| Present bodily autonomy     | 4       | A minor cannot obtain the prohibited surgery even after extensive evaluation and informed assent.                                 |
| Parental authority          | 3       | Parents lose the ability to authorize this treatment in consultation with clinicians.                                             |
| Continued non-surgical care | 8       | Counseling, social transition, and other non-surgical gender-related treatment remain outside the prohibition.                    |
| Equal dignity and access    | 5       | The law need not deny anyone’s identity, but delay, stigma, travel, and coverage loss may burden transgender minors and families. |
| Metric total                | 30      | ★★★☆☆                                                                                                                             |

**INSTITUTIONAL INTEGRITY 28 OF 50 ★★★☆☆**

*The ballot discloses the central prohibition, but purpose-based drafting and incomplete enforcement details create avoidable uncertainty.*

| **Test**            | **Pts** | **Evidence and reason**                                                                                                                     |
| ------------------- | ------- | ------------------------------------------------------------------------------------------------------------------------------------------- |
| Ballot transparency | 9       | The question identifies surgery, minors, the prohibited purpose, covered actors, and the funding and insurance restrictions.                |
| Scope precision     | 3       | The measure does not identify procedures and may reach unintended care if purpose is interpreted broadly.                                   |
| Medical exceptions  | 7       | It protects circumcision, differences of sex development, and acquired abnormalities, but other edge cases may remain disputed.             |
| Enforcement clarity | 4       | Existing regulators can address professionals and insurers, but the text sets no penalty, complaint process, or explicit family protection. |
| Evidence and review | 5       | The policy responds to irreversible risk, but Colorado-specific procedure counts and long-term outcome data remain limited.                 |
| Metric total        | 28      | ★★★☆☆                                                                                                                                       |

**LONG-TERM COLORADO IMPACT 35 OF 50 ★★★★☆**

*A clear adult threshold can prevent irreversible childhood decisions, but humane support and narrow implementation will determine whether the policy endures.*

| **Test**                     | **Pts** | **Evidence and reason**                                                                                                  |
| ---------------------------- | ------- | ------------------------------------------------------------------------------------------------------------------------ |
| Irreversible-harm prevention | 9       | The measure ensures that covered surgery occurs only after the person reaches legal adulthood.                           |
| Mental-health continuity     | 6       | Non-surgical care remains legal, but the statute does not require counseling, crisis support, or protection from stigma. |
| Predictable age boundary     | 8       | A single age rule is easier to understand than inconsistent institutional standards.                                     |
| Unintended medical reach     | 4       | Purpose-based language may delay unrelated or reconstructive care unless regulators and courts apply it narrowly.        |
| Adaptability                 | 8       | Because the measure is statutory, lawmakers can correct overbreadth, enforcement gaps, or harmful coverage practices.    |
| Metric total                 | 35      | ★★★★☆                                                                                                                    |

# OVERALL RESULT

| **Five-category total** | **Normalized score** | **Overall stars** | **Recommendation** |
| ----------------------- | -------------------- | ----------------- | ------------------ |
| 154/250                 | 31/50                | ★★★☆☆             | YES                |

The result supports a YES recommendation because an adult threshold preserves future choice before irreversible surgery. The score remains three stars—not five—because the measure overrides parental and medical discretion, restricts private insurance, may reach unintended procedures, and provides no detailed enforcement or review process. Its legitimacy depends on narrow application and continued respectful care for every child.

# WHAT WE WILL HOLD GOVERNMENT ACCOUNTABLE FOR

Whatever the election result, the publication will compare the promise of protecting minors from irreversible surgery with the law’s actual effect on medical access, mental-health support, privacy, insurance coverage, litigation, and taxpayer cost.

## HOW WE WILL DO IT

**1\. Establish the baseline.** Record the number and type of potentially covered surgeries, payer, patient age range, complaints, denied claims, and state or local spending for at least three years before implementation. Publish only de-identified totals and disclose when small numbers make reporting unsafe.

**2\. Track the actual prohibition.** Report confirmed violations, investigations, professional discipline, insurer actions, and case outcomes. Separate allegations from findings and identify the legal standard used to determine that a surgery had the prohibited purpose.

**3\. Audit denied and delayed care.** Review whether insurers, Medicaid, hospitals, or clinicians deny reconstructive, corrective, injury-related, cancer-related, congenital, or other care outside the measure. Track appeal times, reversals, and medical harm caused by delay.

**4\. Protect the exceptions.** Monitor treatment involving differences of sex development and acquired physical or chemical abnormalities. Require clear guidance, confidential specialist review, and prompt appeals when an exception is disputed.

**5\. Preserve non-surgical support.** Track access to counseling, mental-health treatment, crisis services, social support, and other lawful care. Report wait times, provider availability, and service reductions without exposing individual patients.

**6\. Measure child and family effects.** Use de-identified surveys and public-health data to examine distress, crisis care, out-of-state travel, family disruption, and experiences of stigma. Do not claim that a single policy caused a trend unless the evidence supports that conclusion.

**7\. Protect privacy and dignity.** Publish rules governing medical records, complaints, and investigations. Track breaches, public disclosures, harassment, and retaliation. No minor should become a public example in enforcement reporting.

**8\. Track fiscal consequences.** Compare DORA workload, Medicaid spending, public employee insurance costs, legal expenses, and local-government costs with the Blue Book estimate. Identify savings separately from costs shifted to families or other states.

**9\. Track litigation and federal conflicts.** Publish lawsuits, injunctions, settlements, federal funding disputes, and controlling appellate decisions. State clearly when a court changes the law’s scope or prevents enforcement.

**10\. Require one-, three-, and five-year decisions.** At each review point, recommend whether to keep, narrow, clarify, expand, or repeal the law. Seek immediate correction if enforcement reaches unrelated care, insurers exploit ambiguity, privacy fails, or children lose access to lawful support.

*Primary accountability records: Department of Regulatory Agencies rules, complaints, and disciplinary orders; Division of Insurance bulletins and appeals; Medicaid policy and claims totals; de-identified hospital and insurer data; Department of Law expenses; court decisions; public-health reports; and General Assembly budget documents. Patient identity, diagnosis, treatment history, and medical records must remain confidential.*

# APPENDIX INITIATIVE 110 TEXT

**Source Colorado Secretary of State final text of Initiative 110**

*Be it enacted by the people of the State of Colorado:*

**SECTION 1\. Legislative Declaration. (1) The people of Colorado do hereby find and declare that:**

(a) Children lack the maturity to make permanent, life-altering medical decisions;

(b) Medical treatments or interventions that attempt to surgically alter a minor child’s biological sex often result in serious, irreversible consequences, including sterility;

(c) European nations, including Sweden, Finland, and the United Kingdom, have halted surgery due to the serious and widespread harm resulting from that intervention; and

(d) Colorado law already protects children from other, permanent and potentially life-altering decisions, such as consuming alcohol and smoking. The same protections should apply to irreversible medical interventions related to biological sex.

**SECTION 2\. In Colorado Revised Statutes, add 12-30-125 as follows:**

12-30-125\. Prohibition on surgery for minors – prohibition on state funding for surgery - short title – definitions.

(1) Short title. THE SHORT TITLE OF THIS SECTION IS THE “PROTECT CHILDREN FROM IRREVERSIBLE SEX CHANGE SURGERY ACT”.

(2) Definitions. AS USED IN THIS SECTION, UNLESS THE CONTEXT OTHERWISE REQUIRES:

(a) “ALTERING BIOLOGICAL SEX CHARACTERISTICS” MEANS TREATMENT IN RESPONSE TO A MINOR’S PERCEPTION OF SEX OR GENDER. IT DOES NOT INCLUDE TREATMENT FOR PERSONS BORN WITH A MEDICALLY VERIFIABLE DISORDER OF SEX DEVELOPMENT OR TREATMENT FOR ACQUIRED PHYSICAL OR CHEMICAL ABNORMALITIES. “ALTERING BIOLOGICAL SEX CHARACTERISTICS” DOES NOT INCLUDE MALE CIRCUMCISION.

(b) “HEALTH-CARE PROFESSIONAL” MEANS ANY PERSON LICENSED IN THIS STATE OR ANY OTHER STATE TO PRACTICE MEDICINE, CHIROPRACTIC, NURSING, PHYSICAL THERAPY, PODIATRY, DENTISTRY, PHARMACY, OPTOMETRY, PSYCHIATRY, PSYCHOLOGY, MENTAL HEALTH THERAPY, OR OTHER HEALING ARTS. THE TERM INCLUDES ANY PROFESSIONAL CORPORATION OR OTHER PROFESSIONAL ENTITY COMPRISED OF SUCH HEALTH-CARE PROVIDERS AS PERMITTED BY THE LAWS OF THIS STATE.

(c) “MINOR” MEANS AN INDIVIDUAL WHO IS UNDER EIGHTEEN YEARS OF AGE.

(3) Prohibition on medical interventions on minors. A HEALTH-CARE PROFESSIONAL OR OTHER PERSON SHALL NOT KNOWINGLY PERFORM, PRESCRIBE, ADMINISTER, OR PROVIDE ANY SURGERY TO A MINOR FOR THE PURPOSE OF ALTERING BIOLOGICAL SEX CHARACTERISTICS.

(4) NO STATE OR FEDERAL FUNDS, MEDICAID REIMBURSEMENTS, OR INSURANCE COVERAGE MAY BE USED TO PAY FOR ANY PROHIBITED MEDICAL INTERVENTIONS DESCRIBED IN SUBSECTION (3) OF THIS SECTION.

(5) Severability. IF ANY SECTION OF THIS SECTION IS FOUND UNCONSTITUTIONAL OR INVALID, THE REMAINING SECTIONS SHALL REMAIN IN EFFECT.

**SECTION 3\. Effective date - applicability. This measure shall become effective on January 1, 2027, and apply to violations occurring on or after the effective date.**