How a report led by a right-wing pundit laid the groundwork for upending gender-affirming treatment
Madison Pauly at Mother Jones:
On December 18, Health and Human Services Secretary Robert F. Kennedy Jr. issued a declaration that rebranded transgender medical care as “sex-rejecting procedures” and claimed, erroneously, that the treatments “fail to meet professional recognized standards of health care” when given to minor patients. That same day, his agency proposed a pair of regulations that would curtail access nationwide. The first would forbid federal insurance programs that cover kids in low-income families from paying for puberty blockers, hormone therapy, and the surgery used in rare cases to treat gender dysphoria. The other would deliver an ultimatum to hospitals: Stop providing the treatments to trans kids or get kicked out of the federal Medicaid and Medicare programs.
The rules were designed to be a “nuclear weapon” against trans youth health care, a former domestic policy assistant to President Donald Trump explained at a recent event. Medicaid and Medicare reimbursements cover nearly half of all hospital care spending. “Hospitals just are not in a position to say, ‘You know what? It’s really important to us that we continue to provide this care, and we’re going to forgo payments from the federal government,’” says Lindsey Dawson, director of LGBTQ program at the health policy research firm KFF. The rules are not yet final, but they’ve already sent shock waves through the health care system. Since the start of the year, at least nine hospital systems stopped providing puberty blockers and hormone therapy, including Lurie Children’s Hospital in Chicago and Rady Children’s Health in San Diego, according to a Stat analysis. For a teenager struggling with gender dysphoria, a break in treatment could mean their body proceeds with the puberty of their birth sex, with potentially severe mental health consequences. Blair’s mom worried about her son losing not just his medication, but also the counseling, regular blood tests, and side-effect monitoring he received from his team at the MetroHealth clinic. So after taking some time to think, she wrote a comment on Regulations.gov, beseeching the government to stay out of her family’s personal business.
“I have learned that my original vision of what my child’s life would look like is very different from reality—and yet, this version is just as beautiful, if not more so,” she wrote. “That is why I find it so hard to understand why the government would try to interfere in such personal and medically complex matters.” She’s not the only parent pleading with the Department of Health and Human Services not to cut off their child’s treatment. “Every decision I have made as a parent is to keep my kid healthy and safe,” wrote one of the 30,000-some public commenters on the proposed regulation. “In an emerging culture where parents’ choice is so important to school and child development policies, why is my choice to consult with my child’s medical team and make informed decisions being taken away and infringed on?”
The answer is bound up in a Trump-era political crusade against transgender people, one that has the backing of a small cadre of academics and clinicians who disagree with the position held by virtually all leading US medical groups that gender-affirming treatments are medically necessary for some kids. In its latest attempt to wipe trans health care off the map, the administration drew on a report written by these opponents—none of whom have direct experience providing hormone treatments to trans children and some of whom have a background in anti-trans activism.
Right-wingers began drafting the earliest bans against transgender health care around 2019. Since then, following a coordinated campaign, 27 states now forbid doctors from following mainstream medical standards that regard puberty blockers and hormone therapy as reasonable treatments for teens with gender dysphoria. Such treatments are rare even among the tiny fraction of minors whose doctors have coded them as trans; about 5 percent of them take puberty blockers and 11 percent take cross-sex hormones, per one study of insurance data. Gender-affirming surgeries, also forbidden under the state bans, are even more uncommon. These treatments remain available mostly in Democratic-led states, 14 of which have passed “shield laws” protecting providers from other states’ crackdowns.
The Trump administration’s latest rules would reach past those shield laws by cutting off insurance coverage and threatening hospital balance sheets, creating yet another “significant barrier” to care, according to KFF’s Dawson. Families like Blair’s would need to find new doctors unaffiliated with hospitals—a daunting prospect—and pay out of pocket or with private insurance. “The people who are going to have the hardest time accessing care moving forward are the people with the fewest resources,” Dawson says. Trump’s administration has been laying the foundation for this specific attack since his first day back in the White House. That’s when he issued an executive order instructing federal agencies to “take all necessary steps, as permitted by law, to end the Federal funding of gender ideology.” A few days later came another order that characterized gender-affirming treatments for minors as “blatant harm [that] cloaks itself in medical necessity” and told HHS to do everything in its power to shut down treatments.
But to so dramatically change the way the federal government viewed trans health care would require expertise. So Trump’s order also instructed the agency to produce a report examining evidence and best practices for treating children who present with gender dysphoria or, in its words, “identity-based confusion.” That May, HHS published a several-hundred-page document by anonymous authors whom the White House described as “distinguished scholars.” The report, which HHS said was “informed by an evidence-based medicine approach,” scrutinized the decade-plus of research previously used to support transgender health care for minors and ultimately declared most of the treatments unethical. It suggested that kids with gender dysphoria be treated only with psychotherapy rather than a mix of therapy and hormone treatments medical providers sometimes prescribe. (The report specifically defended the use of so-called “exploratory” psychotherapy, an approach embraced by modern-day conversion therapists that seeks to identify the supposed cause of a client’s transgender identity.) The report didn’t stop there; it also went so far as to question whether the concept of gender—as opposed to sex—was even real.
[...] The HHS report served as the foundation for the new, pending Medicaid rulings that threaten to end pediatric transgender care at hospitals. Who were the “distinguished scholars” who wrote the document, and what experiences informed their analysis? In recent months, more details have come to light, giving more weight to Baker’s and other critics’ charge that the project was political from the start. In November, HHS announced the names of the report’s nine authors. The ringleader was Leor Sapir, a senior fellow at the Manhattan Institute, a conservative think tank perhaps best known in recent years for stoking a right-wing panic around critical race theory in schools. Sapir has long made clear his stance opposing trans rights; in his 2020 political science PhD dissertation from Boston College, he argued that the federal ban on sex discrimination in schools should not be interpreted to also ban anti-trans discrimination. Since joining the Manhattan Institute in 2022, he’s written essay after essay criticizing pediatric transgender health care and its supporters. Then he got the call to spearhead the creation of the new HHS report and recruit its team of authors, as he explained on a recent episode of the City Journal podcast. The idea was to produce a US version of the Cass Review—the controversial 2024 report commissioned by England’s National Health Service that found a lack of methodologically rigorous evidence around medical treatments and social and psychological interventions for kids with gender dysphoria. But the Cass Review took four years; Trump wanted a report within months. “We basically had about eight weeks, nine weeks,” Sapir says on the podcast. The Trump administration “wanted to be able to cite it in their regulatory action,” he goes on to explain. “It’s obviously going to be central justification in the administration’s various actions on this issue.”
[...] Another of the HHS report’s authors was Dr. Michael Laidlaw, a private practice endocrinologist who has been publicly speaking against transgender health care since at least 2018. He’s called gender identity “a fantasy or superstitious belief” and said providers of transgender health care were “deluded by their gender identity phantoms.” At various points, he’s been a member of the American College of Pediatricians (ACPeds), a small but influential group of religious-right doctors originally formed to oppose gay and lesbian couples adopting children, and the Kelsey Coalition, a now-defunct activist group of parents who argued against accepting trans children’s gender identities.
Laidlaw also consulted on one of the earliest bills to ban gender treatments for minors in South Dakota. “These are not physician-patient relationships at all, they are criminal-victim relationships,” he argued in a 2020 email to the bill author. Doctors who provide such care “must be prosecuted by the law,” he insisted. Laidlaw, with his ties to ACPeds, represents the old guard of religious-right doctors who can be counted on by think tanks like the Heritage Foundation and legal groups like the Alliance Defending Freedom to produce research backing conservative social policy on matters like LGBTQ rights and abortion.
But among opponents of transgender health care, there’s also a new guard, neither overtly religious nor partisan. Helping lead it is the Society for Evidence-Based Gender Medicine, or SEGM, a controversial advocacy group of clinicians who are highly critical of gender-affirming treatments for minors. Several of the HHS report’s authors have ties to SEGM. Founded in 2019, the group “frames itself as a secular alternative to the major medical, mental health professional associations’ line on gender-affirming care,” says Joanna Wuest, a scholar researching the anti-trans movement at Stony Brook University. SEGM argues that gender-affirming treatments for youth have an unfavorable risk-benefit ratio: The benefits of treatment are “uncertain,” while the harms, such as the loss of fertility in some cases, are “more certain.” Mainstream medical associations have long taken the opposite stance, citing the evidence that gender-affirming treatments improve mental health and wellbeing for youth with gender dysphoria, as documented in a 2024 review by the University of Utah.
On its website, SEGM says it “opposes all politicization of transgender care” and does not take a position on bans. Yet the Southern Poverty Law Center has classified SEGM as a hate group and describes it as the “hub” of an anti-LGBTQ “pseudoscience network” (characterizations that SEGM rejects). According to an analysis by the watchdog group Documented, a trio of therapists who advised SEGM for years have collectively been affiliated with at least six other organizations whose main purpose is to criticize transgender medical care for minors or to promote non-affirming alternatives.
The Trump Regime plans to finalize a cruel directive that essentially bans gender-affirming care for trans minors.