Mother Jones illustration; Win McNamee/Getty
Blair’s mom had been cautious when she first brought her 6-year-old to the LGBTQ clinic at Cleveland’s MetroHealth hospital, “trying to figure out why he felt different inside,” as she puts it. She didn’t want to rush her child into treatment. So she was grateful to find the clinicians there took a slow and careful approach to Blair’s health care. Over the years they provided open-ended counseling, monitored his hormone levels and bone development, and only progressed with puberty blockers when it was clear that transitioning was making him happier and more confident. “That was my barometer for doing the right thing,” she tells me.
Today, at 16, Blair (a pseudonym to preserve his privacy) has been going to the clinic for a decade, and, by his mom’s account, thriving. Even when Ohio banned transgender medical treatments for minors in 2024, he could stay on his medication thanks to a grandfather clause in the law. But a few months ago, his mom got a message from MetroHealth alerting the family to a new threat.
The rule would deliver an ultimatum to hospitals: Stop providing the treatments to trans kids, or else get kicked out of the federal Medicaid and Medicare programs.
On December 18, 2025, 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 else 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 Trump domestic policy assistant 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 forego 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 shockwaves 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 News 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 not just about her son losing 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 HHS 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 authored 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 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; only 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.
President Donald 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 written 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 report read like “an anti-trans fever dream.”
The report read like “an anti-trans fever dream,” Kellan Baker, a trans health care policy expert and advocate, told me on the day of its release. To Baker, the whole exercise seemed like a charade—“a post-hoc justification for a political agenda they wanted to pursue anyway.”
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 authored 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 its 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 political science PhD 2020 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 Manhattan Institute 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.”
Sapir says he assembled his scholars with an eye for the optics. “I didn’t want this to be perceived as some hit job by a bunch of MAGA-aligned conservatives,” he said on the podcast. Yet he chose eight individuals who all already held positions against gender-affirming treatments for minors, as documented in court testimony, writing, social media posts, or public speaking. Not a single report author was transgender or had direct experience treating trans kids with puberty blockers or hormone therapy.
“Having Sapir at the helm of this project absolutely and completely discredits it as a work of scientific scholarship worthy of the agency,” says Khadijah Silver, director of gender justice and health equity at Lawyers for Good Government. (Sapir declined to comment.)
The nine authors included Duke University professor Farr Curlin, a Christian palliative care doctor who has been arguing since at least 2017 that medical transition for youth is morally problematic and repeatedly testified in favor of banning it. Others were philosophers: MIT professor Alex Byrne, who in 2023 published a book challenging the concept of gender identity, and Colorado State University professor Moti Gorin, who writes frequent commentaries in academic journals criticizing different justifications for transgender care for minors.
One of the report’s authors said that providers of transgender health care were “deluded by their gender identity phantoms.”
Another of the HHS report’s authors was 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 that 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 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 described it as the “hub” of an anti-LGBTQ “pseudoscience network” (characterizations 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.
One of SEGM’s cofounders, William Malone, was involved in early anti-trans legislation; he once suggested language for an Idaho bill forbidding trans people from changing their birth certificates. In 2019, Laidlaw wrote in a letter to Malone that one of his long term goals was to make sure that the Endocrine Society, which publishes clinical guidelines for transgender hormone treatments, was “publicly humiliated and sued mercilessly.”
“It might take years, but we’re going to get them,” Malone replied.
One of the HHS report’s scholars previously worked with SEGM to evaluate the evidence for pediatric evidence for gender dysphoria. Three others have reportedly presented at SEGM conferences. And another author is a SEGM cofounder: Evgenia Abbruzzese, a health care researcher and consultant. (In a statement, the organization said it was “not involved” in producing or directing the HHS report. “This is a relatively small and specialized field in which leading researchers and clinicians frequently know one another and regularly present at the same conferences, including those hosted by SEGM. “)
It was at one such conference, in 2024 in Paris, that Abbruzzese pushed the theory that gender-affirming care for minors has become more common not because it’s helpful but because it makes money for doctors and LGBTQ rights organizations. “These same organizations now are fighting to let lesbian girls remove their breasts by calling them trans men,” she argued, “and by pouring hundreds of millions of dollars in litigations when states step in and say no, minors should not be receiving mastectomies.”
Abbruzzese is right about one thing: Supporters of LGBTQ rights do intend to keep fighting back in court—including against the proposed Medicaid regulations. “I feel very confident that if the rules come out as they were in the draft forms, that they’ll be challenged,” says Jennifer Levi, senior director of transgender and queer rights at GLAD Law. “There are limits to the federal government’s ability to coerce states to regulate medicine in a particular way.”
To Levi, the potential damage of the Medicaid rule goes beyond the loss of health care for trans kids. “Of course it dramatically harms the transgender community,” she says. “But it ultimately erodes public health because you have an HHS that ignores science. That’s bad for public health. It’s bad for all medical care for anyone.”
Advocates like Levi have already succeeded at countering some of the administration’s attacks. Last year, a federal judge blocked Trump’s original executive order threatening to cut federal funding for providers of trans health care, ruling that it likely was unconstitutional because it violated the separation of powers and discriminated on the basis of sex. Lawsuits have halted at least eight subpoenas sent by the Trump administration to hospitals, seeking trans kids’ sensitive medical records. Then, in March, in a response to a lawsuit brought by 21 states and Washington DC, a federal judge in Oregon ruled that RFK Jr. overstepped his authority when he declared unilaterally that pediatric gender treatments “fail to meet professional recognized standards of health care.”
That ruling will prevent HHS from pulling federal funding from providers—for now. But when the Medicaid regulation is finalized, it will create a new pathway for HHS to go after hospitals. “We see the fellow federal administration trying every which way and center to shut down the care,” Levi says. The sheer number of attacks could help prove in court that the government is motivated by antipathy to trans people, she adds.
The Center for Medicaid and Medicare Services could issue a final version of the rules at any time. When it does, HHS is required to evaluate and respond to the public comments on the regulations. That includes the feedback from Blair’s mom, along with the letters written by other parents, doctors, teachers, and allies.
“My entire job as a pediatrician is to ensure that kids are cared for during some of the most vulnerable times,” wrote a commenter. “I believe this decision is being driven by rhetoric and politics, not what is in the best interest of our kids and their families.” “Please do not do this,” another commenter begged. “You are politicizing my child’s mental and physical health.”
Some commenters who identified as trans kids themselves penned pleas. “Gender affirming care is a step to me feeling that I am safe in my own body,” one wrote. “I have this body for a lifetime, why not make it feel like home?”