The federal government on Thursday acted to put an end to gender-related care for minors across the nation, threatening to pull federal funding from any hospital that offered such treatment.
The move reflects the laserlike focus on the issue by President Trump, who in his first days in office called gender treatments for minors “a stain on our Nation’s history.” The administration’s action is not just a regulatory shift but the latest signal that the federal government does not recognize even the existence of people whose gender identity does not align with their sex at birth.
If finalized, the proposed new rules, announced by Health Secretary Robert F. Kennedy Jr. at a news conference Thursday morning, would effectively shut down hospitals that failed to comply. Medicare and Medicaid account for nearly 45 percent of spending on hospital care, according to KFF, a nonprofit health policy research group.
It follows other efforts by the administration to pull back from or eliminate policies that recognize gender identities beyond being born male or female.
“We want our hospitals returning to healing, not harming, the patients entrusted in their care, or they’re going to pay a very steep price,” Dr. Mehmet Oz, the administrator of the Centers for Medicare and Medicaid Services, said at the news conference.
The new rules come one day after a divided House of Representatives voted to approve legislation that would criminalize gender transition treatments for minors and would subject providers to up to 10 years in federal prison. The House is expected to pass another bill Thursday that would bar Medicaid payments for gender-related treatments for minors. The two bills have little chance of passing in the Senate but showed how far the ultraconservative Republican majority was willing to go to deliver on President Trump’s campaign promise to end such medical treatment.
But the proposed rules go much farther, by trying to force hospitals nationwide to stop providing the treatments altogether. The proposed rules for Medicare and Medicaid will be followed by a 60-day public comment period and will most likely be subject to legal challenges before going into effect.If finalized, the rule would be “a death sentence — hospitals have such razor-thin margins as it is,” said Caroline Farrell, a former C.M.S. lawyer, and now an attorney with the firm Foley Hoag. The proposed rule “means just forcing them to stop the care,” she said.
Gender-related treatments for minors, which can include puberty-blocking drugs, hormone therapies and, in rarer cases, surgeries, have been a subject of fierce debate worldwide but are endorsed by most medical groups in the United States.
Mr. Kennedy called out the American Medical Association and the American Academy of Pediatrics at Thursday’s news conference, saying that by endorsing treatments for minors, they had violated their oath to “do no harm.”
“This is not medicine, it is malpractice,” he said.
The A.A.P. condemned the new rules as a dangerous intrusion of the federal government into private medical decisions. “Allowing the government to determine which patient groups deserve care sets a dangerous precedent, and children and families will bear the consequences,” Dr. Susan Kressly, president of the A.A.P., said.
The announcement on Thursday also included other actions: Another C.M.S. rule would prevent Medicaid from paying for the treatments for minors. And the Food and Drug Administration announced that it was issuing warning letters to 12 manufacturers of breast binders, tight garments used to flatten and masculinize chest appearance under clothing, for “illegal marketing” of the products to children as a treatment for gender dysphoria.
Kelley Robinson, president of the Human Rights Campaign, said, “These rules are proposals, not binding law.” She added, “Community members, health care providers, administrators and our allies should be vocal in pushing back by sharing the ways these proposals would be devastating to their families and the health care community at large.’’
Thursday’s announcement follows a clear road map set out by Mr. Trump in executive orders issued in his first days in office that denied the very existence of transgender people. “It is the policy of the United States to recognize two sexes, male and female,” the president wrote.
At the news conference, Jim O’Neill, the deputy secretary of the Health Department, echoed this: “Men are men. Men can never become women. Women are women, women can never become men,” Mr. O’Neill said.
He added, “At the root of the evils we face, is a hatred for nature as God designed it and for life as it was meant to be lived.”
The executive orders also demanded that the department of Health and Human Services produce a report reviewing the evidence for such treatments. A final version of that report, which was written by several vocal critics of the medical treatments on both sides of the political aisle, was released in November.
The report concluded that while the benefits of medical interventions were uncertain, the risks, which can include loss of fertility, were more known. Instead, it prioritized the role of psychotherapy, an intervention that is also supported by little evidence, but that the authors wrote argued had fewer risks.
The Health Department report formed the centerpiece of the new rules on Thursday: Mr. Kennedy cited its conclusions to argue that the treatments do not meet professionally recognized standards for medical care, and that hospitals providing such treatments will therefore be considered to be violating the conditions of participation for hospitals to receive federal funding.
That conclusion is “unprecedented,” Ms. Farrell said. In another arena, abortion, a statute called the Hyde Amendment, passed by Congress in 1976, stipulates that hospitals may not use federal funds to pay for abortions for patients, except in rare cases. But the proposed rule, which does not stem from legislation, goes even further, issuing an existential threat to hospitals that accept any federal funding, even if that money is not used to pay for the treatments themselves.
Questions over the evidence to support medical interventions for minors have been central to debate worldwide as demand for the treatments has increased. An influential report released in Britain last year found that the scientific evidence on the benefits and risks of the treatment was “remarkably weak,” and concluded by recommending that puberty blockers be restricted to research trials only. Several European countries, and most recently New Zealand, have imposed restrictions.
But none of those countries has taken the approach of the United States, where the treatments are now banned in nearly half the country and in some cases criminal charges are threatened against doctors providing them. The new rules add to that by trying to bar any hospital, including in blue states, from prescribing the medications.
Since Mr. Trump took office, several high-profile pediatric gender clinics in blue states have stopped providing puberty blockers and hormone therapies for gender transition, including Children’s Hospital Los Angeles in California, University of Michigan Health in Michigan, University of Pittsburgh Medical Center in Pennsylvania, Fenway Health in Massachusetts and Yale New Haven Hospital in Connecticut.
Children’s Hospital Los Angeles notified staff members in June that their clinic would shutter in late July. In an email announcing its closure hospital leadership told employees that the potential termination of federal funds — which account for 65 percent of its annual funding and enable it to be the largest pediatric safety net provider in California — would be “an existential threat to our hospital operations.”
Parents of trans youth have been on alert for months as the Trump administration applied other forms of leverage to providers of gender-transition care. Some have sought out backup providers, including telehealth providers, who take only private insurance. Some trans teens have been rationing out their medication to last as long as possible in the event of an abrupt cutoff.
State bans on the treatments have proliferated since 2021, when Arkansas became the first state to pass a law barring doctors from prescribing puberty blockers or hormones or performing surgeries on transgender minors.
In June, the Supreme Court ruled that, given the continuing medical debates about provision of gender-related care, states should be able to decide whether and how to provide the treatments to minors. Writing for the majority in upholding Tennessee’s ban on the treatments, Chief Justice John G. Roberts Jr. cited the “fierce scientific and policy debates about the safety, efficacy and propriety of medical treatments in an evolving field” and said the questions should be resolved by “the people, their elected representatives and the democratic process.”
But the new rules would effectively override that decision by forcing blue states to comply with federal orders, said Josh Blockof the American Civil Liberties Union. “The court’s rationale was to defer to democracy and let different states make different decisions,” Mr. Block said, referring to a case challenging Tennessee’s law, United States v. Skrmetti. “This attempt to unilaterally impose a nationwide ban by executive fiat without any actual legislation authorizing it undermines the entire rationale for upholding the law in Skrmetti in the first place.’’
The A. C.L.U., which served as co-counsel on the Skrmetti case, said on Thursday that it planned to challenge the new rules in court.
But advocates said the federal funding rule targets the providers at academic centers, who are best positioned to assess the needs of trans young people and advance research in the field of pediatric gender care. Kellan Baker, a senior adviser for health policy at the Movement Advancement Project, an L.G.B.T.Q. advocacy organization, estimated that there are about three dozen hospitals and community health centers with the interdisciplinary expertise to “optimally provide this care.’’ All of them rely on Medicaid and Medicare as a critical source of revenue.
Earlier this year, the Justice Department issued subpoenas to doctors and hospitals demanding confidential records of the patients they have treated, and announced that manufacturers of drugs used in the patients’ care were under investigation for possible violations of drug marketing laws. The Federal Bureau of Investigation has called on the public to report hospitals and doctors who are performing mastectomies on minors, and the Federal Trade Commission held a daylong hearing devoted to the question of whether providers of transgender medical treatments are engaging in unfair or deceptive trade practices.
Democrat-led states have challenged the Justice Department directives in an ongoing case, and several providers have successfully moved to quash the subpoenas. One group of patients in Pennsylvania and another in Connecticut have filed complaints against providers who have ended their care under state anti-discrimination laws. Several attorneys general in blue states, including Letitia James in New York, have issued guidance reminding providers of their state-level obligations not to back away from providing care.
“A lot of hospitals are in a tough place, being squeezed between state and a federal regulators,” said Katie Keith, director of the Health Policy and the Law Initiative at Georgetown University Law Center.
Timothy Jost, an emeritus law professor at Washington and Lee University and expert on Medicaid and Medicare, said that legal challenges would likely hinge on the first provision in the Medicare statute, which states that the federal government “shall not interfere with the practice of medicine.” The health secretary’s authority to create rules around the participation of hospitals in Medicare and Medicaid, he said, is based on his authority under the Social Security Act to ensure patient “health and safety.”
During the public comment period, “they’re going to receive lots and lots of comments on either side of it,’’ Mr. Jost said. Ultimately, he said, the decision over whether the new rules were ensuring the health and safety of patients would be left up to the courts.
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Azeen Ghorayshi is a Times science reporter.
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