“People are scared out of their minds,” Dr. Miguel Vázquez Rivera tells me.

The psychologist and executive director of the True Self Foundation, an LGBTQ advocacy nonprofit in Puerto Rico, says that he has seen a rise in clinical “anxiety, depression, and suicidal ideation” in transgender people across the island after Puerto Rico’s total ban in July of hormone replacement therapy (HRT), puberty blockers, and gender-affirming surgery for transgender people 21 and younger.

The ban, Senate Bill 350, is among the harshest in any state or territory, criminalizing any provision of gender-affirming care to minors with penalties—up to 15 years in prison, revocation of medical licenses, and fines as high as $50,000—which advocates worry could apply to parents as well as medical providers.

Out of every US state or territory that previously treated gender dysphoria in trans youth, Puerto Rico’s unique age of majority makes its law the most severely punishing: medical autonomy is only conferred at age 21, as are most other adult rights other than purchasing alcohol and joining the military.