How the Federal Government Is Using Every Tool It Has to End Trans Youth Care

This story was originally reported by Orion Rummler of The 19th. Meet Orion and read more of their reporting on gender, politics and policy.

The United States is using the full power of the federal government to restrict gender-affirming care for transgender youth.

The American Psychological Association has accused the Trump administration of ignoring science and undermining mental health through its anti-trans policies. Groups including Planned Parenthood, AIDS United and the Human Rights Campaign see these tactics as a serious threat to the private medical information of everyone, not just trans people. If doctors can’t provide treatment without fear of political retaliation, these advocacy groups say, public health will be harmed.

In response to pressure from the administration, many hospitals across the country have stopped seeing young trans patients, including some in states where gender-affirming care is protected.

Youth transition care is banned in 27 states, according to KFF, a nonpartisan health policy organization — and 24 states impose penalties against healthcare practitioners who provide it. Half of trans teenagers in the United States live in states where care is already banned, per the Williams Institute at the UCLA School of Law.

As a reminder, gender-affirming care in a medical setting refers to taking puberty blockers as a preteen, hormone therapy as a teenager, or, for a small minority of transgender youth, surgery. Not all trans youth pursue all of these treatments.

We break down how federal agencies are taking unprecedented action to keep physicians from providing the care and what’s coming next.

The Justice Department

For over a year, the Department of Justice (DOJ) has been investigating whether off-label promotion or dispensing of puberty blockers and hormones for trans minors violated federal law, like the Food, Drug, and Cosmetic Act (FDCA).

As part of that investigation, the DOJ has tried to force hospitals to share names of patients under 18 who have received gender-affirming care in the past five to seven years, plus names of staff who provided the care. The agency is also digging for internal hospital emails, social media metadata (which includes timestamps and location), and any exchanges with pharmaceutical companies making puberty blockers or hormones.

The DOJ has sent dozens of civil subpoenas to hospitals across the country seeking this information.

Now, the department has escalated this effort through a federal criminal investigation into gender-affirming care. At least three hospitals have received grand jury subpoenas for years of data on adolescent patients: NYU Langone Hospitals and the Mount Sinai Health System in New York City, plus the Lucile Packard Children’s Hospital at Stanford. Two federal judges have halted these efforts; most recently, a judge in early July halted the government from accessing private medical records of minors who received gender-affirming care at the Stanford children’s hospital.

U.S. District Judge Katherine Failla, who blocked the grand jury subpoena into NYU Langone in late June, said the agency’s request “shocks the conscience.”

Many judges have come to similar conclusions.

At least eight federal district courts have blocked or limited civil subpoenas, according to an analysis from researchers at the O’Neill Institute at Georgetown Law. Judges have rebuked the agency for hitting hospitals with overbroad demands for patient data in states where this health care is legal.

The Justice Department has appealed in a bid to enforce civil subpoenas. 

“A lot of the litigation has, importantly, protected patient records,” said Katie Keith, director of the center for health policy and the law at the Georgetown institute. “So far, to date, these court cases have been working.”

But not every hospital sued in response to the government’s demands. Without the paper trail of a lawsuit, researchers don’t know if some patient information has exchanged hands.

Two hospitals have settled with the DOJ. The Cleveland Clinic in Ohio agreed to pay $308,000 to resolve allegations of false billing to insurance companies for minors’ gender-affirming care. The clinic also committed $2 million to restorative care for detransitioners, people who sought a gender transition and then halted or reversed aspects of it. Texas Children’s Hospital will pay $10 million to resolve false billing allegations and plans to open a clinic for detransitioners.

As the agency pursues its investigation, judges are nervous about what the DOJ plans to do with the private medical information of patients that it’s seeking.

In the case involving NYU Langone, Failla said the DOJ had not assured her about how the medical data would be used or that parents of trans youth would not be punished, per the New York Times. During a hearing in late June, a Justice Department lawyer only said that young patients would not be prosecuted.

The Federal Trade Commission

The Federal Trade Commission (FTC) is meant to operate independently of the White House, but the Trump administration has taken steps to sever that independence. Now, targeting gender-affirming care is a priority for the agency, whose job is to protect Americans from deceptive business practices.

In June, the agency sued the World Professional Association for Transgender Health (WPATH), which sets global standards for doctors and nurses treating transgender patients. The FTC accuses WPATH of enabling medical providers to make “false and unsubstantiated claims to parents in order to sell pediatric medical transition services.”

Four states — Alaska, Iowa, Nebraska and Texas — joined the lawsuit alongside the FTC. The complaint was filed in the U.S. District Court for the Northern District of Texas.

Previously, the agency made sweeping demands for internal communications from WPATH, as well as two other nonprofit medical groups that endorse gender-affirming care. The FTC wanted up to a decade of documents from the Endocrine Society, plus information on who at the American Academy of Pediatrics had developed clinical guidance on gender-affirming care.

A federal judge blocked the probes into the Endocrine Society and American Academy of Pediatrics, finding them to be a potential threat to free speech under the First Amendment. The FTC dropped them after it sued WPATH, saying that information from the two medical groups was no longer necessary.

It’s an extreme step to target medical professional associations with investigative demands like this, said Jennifer Levi, senior director of transgender and queer rights at GLBTQ Legal Advocates & Defenders, or GLAD. The group is involved in several lawsuits against the Trump administration. 

The Food and Drug Administration 

The FDA has threatened 12 manufacturers and retailers selling chest binders, which are worn by trans men and nonbinary people to manage gender dysphoria. It has warned them that the binders are medical devices that must be registered with the FDA, according to the Food, Drug and Cosmetic Act.

It is rare for the FDA to send letters like this for low-risk products and even rarer for the agency to issue this kind of warning over a procedural issue as small as failing to register a product, experts say.

The agency has threatened enforcement action like import alerts, seizures and injunctions if “illegal marketing of these products for children” continues. None of the warning letters sent to companies mention selling binders to minors, or list any health risks associated with wearing them. And so far, all of the companies that received warning letters from the FDA in December are still selling chest binders.

The Department of Health and Human Services 

The HHS is using federal health insurance programs for the elderly and disabled as another way to restrict gender-affirming care for trans youth. Hospitals rely heavily on Medicaid and Medicare funds to cover their spending — and the Trump administration has threatened to take away those funds if hospitals don’t comply with efforts to halt gender transition care for minors.

HHS Secretary Robert F. Kennedy Jr. declared last year that the administration would withhold Medicaid and Medicare funds from hospitals that provide gender-affirming care to minors. A judge intervened in April, stating that the agency cannot interfere with state standards for gender-affirming care.

“I think it’s very odd that they have not appealed yet,” said Keith from Georgetown Law, referring to the Trump administration.

However, the agency’s proposed rule to bar Medicaid and the Children’s Health Insurance Program (CHIP) from covering the care for trans youth is still progressing. The rule has been sent to the White House for review.

Throughout this year, HHS General Counsel Mike Stuart has also referred many children’s hospitals to the agency’s inspector general — but these investigations don’t really have teeth, experts say. 

“It’s an announcement made for the purpose of intimidating providers, clinics and hospitals,” Levi from GLAD said. Regardless, in response to another lawsuit, the agency agreed to pause potential punitive action against those hospitals.

In many cases, the administration’s attempts to intimidate hospitals from providing gender-affirming care to minors is working. Hospitals in blue states like Massachusetts and New York have continued to halt care — even after judges sided with their states against the Trump administration. Families are left to find alternatives in states where, according to state law, gender-affirming care is still legal.