One morning in February, 16-year-old Levi Hormuth took off school, his parents called out of work, and the three began a five and a half hour drive.

The purpose of the 350-mile trip from their home in St Charles county, Missouri, to Chicago, Illinois, was a routine doctor’s appointment.

Levi, a transgender boy, now 17 and in his final year of high school, had been a patient at the Washington University (WashU) Transgender Center since he was 13. The center, a short drive from home, had helped Levi in his transition, providing counseling and eventually hormone treatments at age 15. The testosterone had profoundly positive impacts, Levi and his parents said, helping him overcome significant mental distress stemming from his gender dysphoria.

But in June 2023, Missouri’s Republican governor enacted a bill banning gender-affirming healthcare for youth under 18. The law had an exception for youth like Levi who were already accessing the care, but WashU, fearing legal liability, stopped prescribing medications to all trans youth.

The best alternative for Levi and his family was to cross state lines.

“The fact that I have to drive five hours both ways for treatment just shows our government in Missouri doesn’t care about things that are actually important,” Levi said one afternoon, sitting on his backyard deck with his parents in St Charles, a county that is more conservative than neighboring St Louis. “We have potholes galore that should be fixed, we have horrible crime rates. It’s enraging that they’re not focusing on what matters and listening to our voices.”

The stakes of the presidential election are enormous for people like Levi and the broader LGBTQ+ community.

Donald Trump has promised aggressive attacks on LGBTQ+ rights, with a focus on trans youth, who have been a central target of the GOP’s culture war. The former president’s proposed “plan to protect children from left-wing gender insanity” includes ordering federal agencies to end all programs that “promote … gender transition at any age”; revoking funding from hospitals that provide gender-affirming care to youth and subjecting them to US justice department investigations; punishing schools that affirm trans youth; and pushing a federal law stating the government doesn’t legally recognize trans people.

Trump has also pledged to rescind federal LGBTQ+ nondiscrimination policies, which could mean a loss of protections in housing, healthcare, employment, education and a range of federal programs. He has promised new credentialing for teachers to “promote positive education about the nuclear family, the roles of mothers and fathers”. The GOP platform calls for advancing a “culture that values the sanctity of marriage”.

Project 2025, the rightwing manifesto authored by Trump allies, is even more explicit, saying Biden-Harris pro-LGBTQ+ policies should be replaced by ones supporting the “formation of stable, married, nuclear families” and “heterosexual, intact marriage”. It says adoption agencies, healthcare workers and businesses should be able to reject LGBTQ+ people, and faith-based government contractors should be allowed to deny services to people who don’t fit “biblically based” definitions of marriage.

Some legal scholars have warned that marriage equality, already endangered at the supreme court, could be further threatened under Trump, particularly if he gets the opportunity to appoint additional justices.

“It is terrifying to think about our government actively, strategically and intentionally coming for our community in every aspect of our lives,” said Cathy Renna, communications director of the National LGBTQ Task Force Action Fund, a national rights group. “These attempts to erase our community would have just absolutely devastating impacts.”

‘It’s life and death’

If elected, Trump is expected to weaponize the US government to authorize, encourage and mandate widespread anti-LGBTQ+ discrimination.

In his first term, Trump banned trans people from the military, and Project 2025 calls for the policy’s reinstatement. The Republican presidential nominee is also likely to assert that employers’ “religious beliefs” provide a lawful justification for firing LGBTQ+ workers, either through an executive order or regulations, the ACLU recently warned.

LGBTQ+ people could also be denied housing under a new Trump term, which could see a return to his efforts to exclude trans people from homeless shelters, said Sarah Kate Ellis, CEO of GLAAD: “Everything is at risk for us in the election – our workplace, our relationships, our families, our marriages, education, our housing.”

Advocates fear Trump’s anti-LGBTQ+ agenda would undo the Biden administration’s foster care regulations meant to ensure queer and trans youth are placed in supportive homes. Brandon Wolf, press secretary of the Human Rights Campaign, a national LGBTQ+ group, said that rollback would endanger kids’ lives, noting survey data suggesting half of trans and nonbinary youth have considered suicide. He recalled being a teenager in Oregon when the state banned gay marriage and how that emboldened his classmates’ homophobia

“It’s not easy to be a young person when your president is demeaning, demoralizing and dehumanizing members of your community,” Wolf said, “and Trump would be catastrophic”.

Project 2025 further equates trans-inclusive reading materials to “pornography”, suggesting teachers and librarians should be imprisoned as sex offenders if they promote “transgender ideology”. This would likely require a law from Congress, but the push echoes GOP state bills across the country seeking to criminalize drag art and gender nonconformity. And Trump himself has increasingly spread blatant misinformation fearmongering about trans kids’ healthcare.

Beyond explicit attacks on LGBTQ+ rights, advocates fear the politicization of federal public health agencies could impede critical research and HIV prevention efforts. “The support we get from the federal government, while it might not be enough, is what’s keeping some people alive,” said Dwayne Kwaysee Wright, a director of DEI initiatives at George Washington University. “So the stakes are no more than life or death.”

Alexander Chen, founding director of Harvard Law’s LGBTQ+ advocacy clinic, who previously helped challenge the trans military ban, said a second Trump term could be “much more dangerous” than his first. As president, Trump introduced some of his most extreme policies in a chaotic, brash manner – including via tweets, with little thought to legality or implementation – resulting in successful court challenges. With support from conservative groups like Project 2025, Trump 2.0 could be significantly more strategic and effective if he returns to the White House.

Kamala Harris has not released detailed LGBTQ+ rights policies, but her platform says she would fight to pass the Equality Act, which would enshrine LGBTQ+ protections into law. As a California prosecutor, she was an early champion of marriage equality, but had a mixed record on trans rights; she has since earned support from some prominent trans advocates and major LGBTQ+ groups.

The ACLU has urged Harris to build on Biden’s legacy and fight to protect LGBTQ+ people from state attacks on their rights and expand access to trans healthcare in federal programs.

A Trump spokesperson declined to comment on specific policies, and said in an email: “President Trump will implement policies that uplifts ALL Americans, regardless of race, gender, or sexual orientation.” The Harris campaign did not respond to inquiries.

‘This could break me’

Missouri, a national leader in anti-trans policy, offers a window into the hostile climate Trump and his allies seek to expand. It is one of 26 states that have restricted gender-affirming healthcare, affecting an estimated 118,300 trans kids ages 13 to 17.

Studies have found that care is linked to improved mental health. But in recent years, there’s been a growing movement to criminalize those treatments for trans youth, pushed by the same groups promoting anti-abortion laws forcing patients to cross state lines for procedures.

Sixteen Democratic-run states and Washington DC have pushed back, adopting “sanctuary” laws protecting gender-affirming care, according to Elana Redfield, federal policy director at UCLA’s Williams Institute. “There’s evidence it’s beneficial for trans people to get this care, so to have it rapidly restricted is likely very distressing,” she said.

Levi, the St Charles teenager, was isolated and detached before he transitioned, his parents recalled. He didn’t want to go out in public. He’d have meltdowns and remain balled up in his closet. He struggled with self harm. Once he expressed his identity and the family met with experts who helped them understand gender dysphoria, “he came out of his shell and became a totally different person, a joyous person, a really fun kid,” said Becky Hormuth, his mother, who is a teacher. “It’s unimaginable to think he can be this joyous when the entire world is pretty much attacking his existence.”

Kyle Hormuth, Levi’s father, who works in healthcare, said when it became clear gender-affirming treatment could help address his son’s suicidality, “we jumped right on board. I’ll support my children no matter what because I’d much rather have my child in my life than not in my life. I want my kids to live and thrive and be what they want to be.”

After Missouri’s ban passed, Becky got Levi on a waitlist for a Chicago clinic, but for months it was unclear if he’d be accepted “That’s when I really started to spiral into a panic”, he recalled.

She started rationing Levi’s treatments. It was a relief once they got into Chicago, but the travel was exhausting. Levi had to cross into Illinois again weeks after his first visit to do bloodwork, which was required to be done within the state.

Losing access to testosterone wasn’t an option, Levi said, his eyes welling with tears: “After all of this holding myself together, that would probably be the thing that breaks me.” He said he recognized some people were uninformed about trans identities:. “People fear what they cannot understand.” But he was fed up with those in power unwilling to learn. “How am I supposed to talk to you if you aren’t going to listen?”

Becky said the constant attacks on their rights had caused great anxiety. “When I’m at a store, I scan the room and wonder, are you a hateful person? Are you someone who thinks vile things about my family and the community I advocate for?”

The Hormuths have considered leaving Missouri, but Levi wanted to stay in his school to support younger LGBTQ+ kids.

Younger trans kids are particularly vulnerable if Trump is re-elected.

William, an 11-year-old trans boy in St Louis, was adamant about his gender from a young age, said his mother, Marie, who asked to use their middle names to protect their privacy. Just before he turned seven, the two heard a radio segment about a trans woman who was killed, prompting her to explain anti-trans discrimination.

“His takeaway was: ‘That is how I feel. I think I’m trans. Does that mean I’m going to get killed, too?’” Marie recalled. She was glad the conversation gave him language to express himself, but regretted the fear it instilled. Once he spoke openly about being a boy, the depression he’d been suffering dissipated. “He said, ‘I just feel so much better.’ He was bouncing off the walls like a balloon, so happy and free.”

William had a supportive gender-affirming healthcare team, which was on track to prescribe puberty blockers after years of living as a boy – until the GOP criminalized this treatment. “It’s terrifying and extremely stressful,” said Marie, who eventually got William seen at a clinic in Peoria, Illinois, two and a half hours away. But that facility didn’t offer prescriptions he needed, forcing her to seek an appointment in Chicago. “I keep having to start all over,” said Marie.

Seated with his mother outside the food business she runs one afternoon, William was cheerful, talking about how popular he was at summer camp, his love of sleepovers, his plans to swim with dolphins, his dreams of being a baseball announcer and how he chose his name based on his first crush. “It’s embarrassing but I was so young and mindless then,” he admitted.

He said he didn’t mind the drive to Peoira, because his mom got him donuts. He knows they may have to go to Chicago next. “My mom’s gonna feel bad, so I’ll get to stay in a hotel and get snacks and movie night.”

“We’ll do our best to make it fun,” added Marie.

William’s message to lawmakers forcing him to go across state lines?

“Trans people are just other humans,” he said. “If they put themselves in my shoes, they’d change their mind.”