The Centers for Medicare & Medicaid Services (CMS) took early steps this week to pressure hospitals against the delivery of gender-affirming care to children and adolescents—a key policy of the Trump administration that has so far faced pushback from blue states, transgender rights advocates and the courts.
Wednesday, the agency sent a special alert to hospitals across the country that it “may begin taking steps to appropriately update its policies to protect children from chemical and surgical mutilation,” language the White House has used in executive orders to describe hormonal treatments and surgical procedures used in transition-related care.
The notice and an accompanying press release also said the CMS “may” be looking to adjust regulations and “take additional appropriate actions” related to restricting those services and said that “similar alerts” are being sent to other Department of Health and Human Services agencies and grantees.
Though the alert outlines federal health agencies’ ideological shift on the issue and signals intent for future activity, it does not explicitly outline new requirements or restrictions for hospitals.
“CMS will continue to follow any applicable substantive and procedural requirements in taking any future action,” the agency said.
The CMS said its position is backed by inconclusive research findings on how hormonal treatments and surgical procedures impact individuals whose bodies are still undergoing development. To support that stance, it cited a combination of journal articles, news reports, legal briefs, provider resources—some of which were outwardly supportive of gender-affirming care—and trackers developed by advocacy groups that oppose gender-affirming care in minors.
The agency’s alert also described the U.S.’ government’s prior support of these treatments as an “outlier” among other developed nations. It pointed to policies or recommendations emphasizing psychotherapy as a first-line treatment promulgated in the U.K., Sweden and Finland.
Gender-affirming care services comprise a range of social, behavioral and medical interventions that affirm an individual’s gender identity when it conflicts with the gender they were assigned at birth.
The services are supported by major medical groups such as the American Academy of Pediatrics, the American Medical Association, the American Psychological Association and numerous others that warn of transgender individuals’ elevated risk for self-harm when denied affirming treatments.
Advocates and providers of the services also note that the interventions that receive the most attention from critics, such as surgical procedures, are generally rare among minors and require parental consent.
About 300,000 youth aged 13 to 17, or about 1.4% of the U.S. population, identify as transgender, according to the Williams Institute at the UCLA School of Law. A Reuters and Komodo Health analysis of insurance claims, which was cited in the CMS alert, found 1,390 claims of new use of puberty blockers among patients aged 6 to 17 in 2021, 4,231 for new use of hormone therapy among those aged 6 to 17 and 282 “top surgeries” among those aged 13 to 17.
President Donald Trump’s first day in office brought an executive order that forbade the federal government from funding, sponsoring, promoting, assisting or supporting subsets of gender-affirming care services, including hormonal treatments and surgical procedures, in those 19 years and younger. During his March 4 address to lawmakers and the nation, the president called for those restrictions to be codified in federal statute.
The days immediately following Trump’s order saw several gender-affirming care providers either pause or initiate a review of their gender-affirming services as well as warnings from blue state attorneys general that withholding those services would violate antidiscrimination laws.
Those states, as well as LGBTQ+ rights groups, have brought legal challenges against Trump’s ban on gender-affirming care and another order opposing “gender ideology.” To date, two federal judges have granted preliminary injunctions against portions of the orders and said that the policies are damaging to patients and likely unconstitutional.
Though the CMS’ Wednesday notice brings no new regulations or requirements, it does appear to be teeing up a conflict for hospitals navigating the law and their continued participation in federal funding programs like Medicare.