Texas Governor Greg Abbott directed state health agencies Tuesday to investigate medical treatment of transgender youth as “child abuse.”

Abbott’s directive follows a Friday opinion by Texas Attorney General Ken Paxton, which found that “each of the ‘sex change’ procedures and treatments enumerated above, when performed on children, can legally constitute child abuse under several provisions of chapter 261 of the Texas Family Code.”

Paxton wrote:

Beyond the obvious harm of permanently sterilizing a child, these procedures and treatments can cause side effects and harms beyond permanent infertility, including serious mental health effects, venous thrombosis/thromboembolism, increased risk of cardiovascular disease, weight gain, decreased libido, hypertriglyceridemia, elevated blood pressure, decreased glucose tolerance, gallbladder disease, benign pituitary prolactinoma, lowered and elevated triglycerides, increased homocysteine levels, hepatotoxicity, polycythemia, sleep apnea, insulin resistance, chronic pelvic pain, and increased cancer and stroke risk.

In his letter, Abbott wrote, “Texas law imposes reporting requirements upon all licensed professionals who have direct contact with children who may be subject to such abuse, including doctors, nurses, and teachers, and provides criminal penalties for failure to report such child abuse.”

Abbott’s letter comes amid a wave of state attempts to criminalize medical care for transgender youth. Arkansas lawmakers overcame the governor’s veto to pass a bill last April banning the provision of gender-affirming care to transgender minors. That law was temporarily blocked by a federal judge in July. Similar bills have been introduced in Texas and several other states but have not yet been passed. Numerous experts have stressed that gender-affirming care is essential to the health and wellbeing of gender-diverse youth and can even save lives.