Republican-led state legislatures are considering a new round of bills restricting medical care for transgender youths — and in some cases, adults — returning to the issue the year after a wave of high-profile bills became law and sparked lawsuits.

As legislatures begin their work for the year, lawmakers in several states have proposed enacting or strengthening restrictions on puberty-blocking drugs and hormone treatments for minors. Bills to govern the pronouns kids can use at school, which sports teams students can play on, and the bathrooms they can use are back, as well, along with efforts to restrict drag performances and some books and school curriculums.

LGBTQ+ advocates say that most of the states inclined to pass bans on gender-affirming care have done so, and that they now expect them to build on those restrictions and expand them to include adults. With legislatures in most states up for election this year, transgender youths and their families worry about again being targeted by conservatives using them as a wedge issue.

They include Mandy Wong, a mother in Santa Barbara, California, who said she’s tired of conservative politicians using transgender children as “campaign fuel.” While she doesn’t expect such a policy to pass in her Democrat-led state, Wong said, her child and his friends feel emotionally drained.

“It was just heartbreaking to tell him … I don’t think this is going away anytime soon,” she said. “All the negative attention trans kids, even us as parents, have gotten because of these proposals doesn’t seem to be dying down.”

In South Carolina, one of the few Southern states without a ban on gender-affirming care for minors, a House committee voted Wednesday to send a ban to the House floor. The bill, sponsored by the state’s Republican House speaker, would also prevent Medicaid from covering such treatments for anyone under age 26. And last week in New Hampshire, the House voted to ban gender-transition surgeries for minors.

At least 22 states have enacted bans on gender-affirming care for children, with most of them approved in the past year. Those who support the bans say they want to protect children and have concerns about the treatments themselves. Major medical groups, including the American Medical Association and the American Academy of Pediatrics, oppose the bans and have endorsed such care, saying it’s safe when administered properly.

Last year’s limits included a Florida law that has made it nearly impossible for many transgender adults in the state to receive gender-affirming care. Florida Gov. Ron DeSantis has promoted that ban as one of his accomplishments as he seeks the Republican presidential nomination.

“They’ll stop at nothing, so we don’t know what exactly to anticipate (in 2024),” said Katy Erker-Lynch, executive director of PROMO, an advocacy group in Missouri, where lawmakers have proposed more than 20 bills targeting LGBTQ+ people.

Bills filed in Missouri include efforts to remove two provisions that were key in overcoming a Democratic filibuster to that state’s ban on gender-affirming care for youths. The new Missouri Freedom Caucus is prioritizing a bill that would make the ban on gender-affirming care for minors permanent, removing a provision that allows it to expire in 2027. Legislation would also remove a clause that allows minors who began the care before the law went into effect to continue with it.

Republican state Sen. Mike Moon, who is sponsoring bills both to repeal the expiration date on the medical restrictions and to require schools to tell parents if a student wants to go by a name or pronoun other than the one the parent used to register the child for school, compared transgender medical restrictions for minors to age thresholds in laws for smoking, drinking and driving.

“Children, especially younger children, don’t make good decisions, and they’re not certain exactly what reality is sometimes,” Moon said.