Temporary regulations on gender transition hormonal therapies for youth under 19 took effect in Nebraska on Sunday following the state's ban on gender transition surgeries for minors.

The state's Department of Health and Human Services published temporary guidelines on Sunday mandating that patients under 19 receive 40 hours of psychological therapy focused on gender identity before being prescribed puberty blockers or cross-sex hormones. Patients under 19 must also obtain parental permission and follow a seven-day waiting period before starting hormonal therapy for gender transition.

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Nebraska Chief Medical Officer Timothy Tesmer, appointed by Gov. Jim Pillen (R-NE), proposed the temporary rules in light of the legislation banning gender transition surgeries for minors, which passed 33-15 in Nebraska's unicameral legislature in May. The proposed rules will be in effect for 90 days of public comment before final rules on hormonal treatments are issued.

A draft of the proposed final rules will be made available 30 days before a public hearing scheduled for Nov. 28 in the state capital of Lincoln.

Over 100 protesters gathered outside of the state Capitol building on Sunday to protest the institution of the ban on youth transition surgeries. The protest was organized in part by the American Civil Liberties Union of Nebraska and Planned Parenthood Advocates of Nebraska.

At least 22 states have passed legislation restricting gender transition medicine for minors. A ban in Arkansas resembling that of Nebraska was overturned by a federal judge in June. That case is being appealed in the 8th U.S. Circuit Court of Appeals, which has Nebraska in its jurisdiction.

The American Academy of Pediatrics has committed to its affirmation of gender transition medicine for minors as a key treatment to preventing suicide and self-harm for transgender youth, but the effectiveness of gender transition medicine is still debated in the medical community.

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In July, an international group of 21 endocrinologists, who specialize in the medical science of hormones, contradicted the AAP's endorsement of gender transition medicine for minors, citing a lack of evidence for its efficacy.

The letter was mainly written by European physicians from Finland, the United Kingdom, Sweden, Norway, Belgium, France, and Switzerland, along with a few South African and American doctors.