Trump administration finalizes rule to end federal support for gender-affirming care

The Trump administration finalized a rule on Tuesday to end gender-affirming care through Medicaid and the Children’s Health Insurance Program (Chip), a move that will make it harder for vulnerable children to access healthcare and that eschews evidence to advance an anti-transgender ideology, opponents say.

The rule is set to take effect on 13 October – but legal challenges could delay or block it entirely.

Ending federal funding for children receiving gender-affirming care was first proposed in December, and it received nearly 35,000 comments, about 90% of them opposing the change, said Ma’ayan Anafi, senior counsel for health equity and justice at the National Women’s Law Center (NWLC).

The NWLC outlined concerns in one such comment, including pages of evidence on the benefits and safety of gender-affirming care.

“This is an incredibly dangerous rule,” said Anafi. While advocates have prepared for the policy since it was proposed late last year, it is still “incredibly distressing for our community”, they added.

The US Department of Health and Human Services (HHS) pointed in a press release to international reviews of the medical evidence such as the Cass Review in the United Kingdom, which has been widely criticized for skewing the evidence, but it did not include the more recent landmark report from the Netherlands finding that gender-affirming care is safe and effective, and should be widely supported.

The new HHS policy is “not about following the science. It’s about promoting this administration’s anti-transgender agenda,” Anafi said. “This stigma is really the primary function of this rule.”

It could also add fuel to the rhetoric increasingly being used in state-level bans and restrictions on care.

Also in December, HHS proposed a rule that would prevent any health systems receiving Medicaid and Medicare payments – which is the vast majority of health systems in the US – from providing gender-affirming care, but there have been no further announcements on that proposal.

At the same time, HHS immediately began using a little-known statute to refer health systems to prosecutors for offering gender-affirming care, which led to dozens of major providers abruptly ending care across the country. A federal judge blocked the administration from pursuing this prosecution in an April decision that chastised HHS secretary Robert F Kennedy Jr for his “wanton disregard” for the law that “causes very real harm to very real people”, deeming his actions “unsafe”.

On 3 August, federal employees and their families filed a class-action lawsuit against the Trump administration for ending insurance coverage for gender-affirming care.

Legal challenges to the new rule could delay or block the policy entirely, Anafi said: “A lot of courts have recognized that these actions are based on prejudice and they’re not based on evidence – they’re actually contrary to the evidence.”

If it does take effect, there are other options for providing the care. States could use their portion of Medicaid funds, not reimbursed by the US government, to cover gender-affirming care, and individuals and organizations may also ramp up mutual aid efforts.

Gender-affirming care can include puberty blockers or hormones like estrogen and testosterone, and sometimes it involves surgery, though that’s less common among children. It also includes medical monitoring, such as bloodwork for tracking puberty, and support for children and families.

If the new policy takes effect, children on Medicaid and Chip would be given up to six months to taper off their medications.

“Whenever we see restrictions on care that are based on politics and ideology, we know that patients are ultimately suffering,” Anafi said.

The Trump administration has focused on the cost of gender-affirming care in its arguments for ending it.

“America’s children will not be subjected to life-altering interventions on the taxpayer’s dime without reliable evidence of safety and clinical benefit,” said HHS spokesperson Emily Hilliard, adding that “federal health care dollars will support evidence-based care that protects children and puts their long-term health first” and that “American taxpayers should never be forced to finance interventions” like gender-affirming care.

Healthcare for trans people, including youth, is evidence-based, safe and effective, and can have life-saving benefits. But restrictions can affect access to care and even amount to an unofficial ban.

“We’ve also seen it for years when it comes to politically motivated restrictions like for abortion care,” Anafi said. “So we know that this kind of interference means that people will struggle to get the care they need, and if they can’t get access to that care, it can have enormous repercussions for their health and their wellbeing.”

People who are enrolled in Medicaid and Chip are far less likely to have alternatives for funding their care like paying out of pocket. And young people enrolled in Medicaid already face significant barriers to healthcare; they are more likely to be living in poverty, more likely to be people of color, more likely to be disabled – all factors that affect access.

“So this rule is like harm upon harm upon harm,” Anafi said. “It is exacerbating barriers to care for people who are already facing the greatest barriers.”

Allowing political appointees to determine which medical care is available is an alarming precedent for all types of care, Anafi said: “It doesn’t stop with trans people. It is something that can be weaponized against people across this country.”

But the backlash against policies like these is growing.

“With this particular rule, we saw enormous pushback against the misinformation and prejudice,” Anafi said. “It shows the strength of the resistance.”

Reporting from The Guardian contributed to this story.