Hospitals Are Curtailing Gender-Affirming Care Beyond Scope Set by Trump’s Order

Sterling Misanin, 32, had waited six months for his gender-affirming procedure to be scheduled and pre-authorized by his insurance company. Last June, the long-awaited appointment was finally on the horizon — or so he thought.

Four days before his scheduled hysterectomy, Misanin received a call from the Medical University of South Carolina (MUSC), informing him that his appointment had been canceled. The public medical university — one of the largest providers of transgender care in the state — said it could no longer perform the surgery due to the enactment of a state law banning transition-related procedures for minors and prohibiting state funds from paying for such care for people of all ages.

“It was devastating,” said Misanin, who is now the lead plaintiff in a lawsuit challenging the state’s ban.

Misanin is one of a growing number of transgender adults — including those with private health insurance — who say their access to gender-affirming care has become increasingly difficult due to state policies ostensibly intended to ban this type of care for minors. Now, trans patients and their advocates say an executive order signed by President Donald Trump may add additional barriers to care for trans people of all ages.

On January 28, Trump signed a sweeping order titled, “Protecting Children From Chemical and Surgical Mutilation,” which calls for the defunding of institutions that provide gender-affirming care to people under 19, including by stripping them of educational and research grants, as well as Medicaid and Medicare reimbursements. The order directs leaders within government agencies, including the secretary of the Department of Health and Human Services, to issue a report outlining how they will comply.

Several lawsuits have since been filed to prevent the Trump administration from enforcing the executive order. In February, a federal judge in Maryland issued a temporarily restraining order in a case filed by the ACLU and other groups, preventing the order from being enforced nationwide.

Though it did not enact any legal or regulatory changes, the executive order immediately prompted several hospitals across the country — including in New York, Los Angeles and Washington, D.C. — to at least temporarily shutter or curtail gender-affirming care to people under 19. (Some of the hospitals that initially curtailed their gender-affirming care programs for people under 19 have subsequently resumed providing care).

“They’re beta testing this on a small number of people to see what kind of pushback they get.”

In interviews, attorneys and advocates reflected on what they’ve learned from Medicaid and public funds passed at the state level, including that these restrictions are designed to intimidate medical institutions into abandoning transition-related care, even when they are not required to under the letter of the law.

Experts also warned that the executive orders issued could be interpreted to restrict federal funding on gender-affirming care for people of all ages. Simone Chriss, an attorney with Southern Legal Counsel who has litigated against Florida’s all-ages Medicaid ban, told Truthout that it’s “without question” that 18-year-olds were included in the executive order to try to expand the restrictions to all trans people down the line: “They’re beta testing this on a small number of people to see what kind of pushback they get.”

Rapid Growth of State Laws

Just a few years ago, it seemed that bans on public funds being used for gender-affirming care were headed for the history books. Between 2000 and 2020, many state policies that had for decades prohibited Medicaid from covering transition-related hormones and surgery were ruled unconstitutional and overturned. But then the landscape shifted once again: In the past four years, eight states have implemented bans on Medicaid or other private funds being used for trans care, according to data compiled by the Movement Advancement Project, an LGBTQ think tank, and these bans have affected patients on both public and private insurance plans.

Currently, 10 states have Medicaid policies that explicitly exclude transgender-related health care for people of all ages, and three additional states have Medicaid restrictions for transgender youths specifically. According to a December 2022 report by the Williams Institute at UCLA, a combined 58,000 transgender people were on Medicaid in the 10 states that currently have these bans in place. (This number does not include individuals like Misanin, who are impacted by public funds bans despite being covered by employer-sponsored insurance.)

In states that have imposed Medicaid or other funding bans, some trans adults say they have faced devastating consequences. In Florida, restrictions came into force in 2022, after the Florida Agency for Health Care Administration issued a rule (that later became encoded as a law) prohibiting the state’s Medicaid program from covering gender dysphoria treatments for people of any age. (Although a Florida district court ruled in 2023 that the state’s all-age Medicaid ban was unconstitutional, the state is still refusing to pay for most gender-affirming care, according to ongoing litigation. The case was heard by the Eleventh Circuit in November.)

AP, 19, a resident of Ocala, Florida, said Medicaid rejected his claim for reimbursement for topical testosterone, stating in a May 2024 letter that medications “must meet acceptable medical standards and not be experimental or investigational.” The letter specified the drug would only be covered for males with low testosterone levels. At the time, AP and his mother were living off about $2,000/month. By using the drug coupon website GoodRx, AP was able to bring his hormone costs down from $400 to about $112/month, which he pays for out of pocket. (He asked for his initials to be used to protect his privacy.)

“Effectively, these are bans on health care, not just bans on Medicaid paying for it.”

“I basically have just been miraculously scraping by every month,” he said.

Gender-affirming surgeries can cost upwards of $100,000, an out-of-pocket sum far out of reach for most people, especially those on Medicaid, which is geared toward adults and children with limited income and resources.

“Effectively, these are bans on health care, not just bans on Medicaid paying for it,” said Logan Casey, the director of policy research at the Movement Advancement Project.

Idaho passed a bill into law last year banning the use of taxpayer dollars or government facilities for gender-affirming care. Howard Belodoff, an attorney with the Idaho Legal Aid Society, sued the state on behalf of several trans plaintiffs affected by the law, including six adults. Since the law came into force, one of his adult clients lost access to their hormones for several months. All have gone to great lengths to avoid interruptions in treatment. He said his clients haven’t run out of their transition-related medications yet, since they stockpiled them before the law went into effect, but he’s worried about what happens when these prescriptions run out.

“They rely on their families for help paying for medications. They rely on friends and online fundraisers. They find other ways, because they just can’t afford it, so they have to think outside the box. They don’t have the resources to purchase the medications, and they don’t have the resources to continue treatment with their doctors,” Belodoff said.

As Sterling Misanin discovered last year, state laws that include public funding bans for transition-related care can prompt health care institutions to cease providing this type of care altogether, affecting a much broader population than the law explicitly targets.

When Misanin first heard about South Carolina’s transgender care restrictions, he didn’t think it would affect him — an adult with private health insurance.

“My mentality when I was reading it was that this really stinks, but at least it won’t impact my care,” he said.

After having his surgery appointment canceled by the Medical University of South Carolina just days before his scheduled procedure, Misanin was eventually able to undergo the procedure at a different facility. However, according to his lawsuit against state officials and MUSC, this entailed another pre-authorization from his insurer, additional personal expenses, a delay of treatment and the lack of continuity of care with his primary provider at MUSC.

Sruti Swaminathan, an attorney at the ACLU’s LGBTQ & HIV Project, who is representing Misanin and other transgender South Carolinians in the lawsuit, said MUSC opted to cancel care out of fear and confusion about how to comply with the state’s trans care law.

These laws are intentionally written with broad and vague language, so organizations that are worried about possible penalties opt to self-enforce.

“What they’ve said is that their funds are so intertwined and commingled that it’s impossible for them to parse out what sources touch state funds versus private funding,” Swaminathan said. “And because of that, they just needed to shut down all of the gender-affirming care they provide at the institution — because they’re frankly worried that they could be construed as violating the law.”

Harper Seldin, an ACLU senior staff attorney also representing Misanin and his co-plaintiffs, said these laws are intentionally written with broad and vague language, so organizations that are worried about possible penalties opt to self-enforce.

“They stop providing care that perhaps they could continue to provide in some fashion under the exact text of the law,” Seldin said.

It’s not just hospital-based gender-affirming care programs that have shuttered after the implementation of public fund and Medicaid bans. After the passage of Idaho’s law, Health West, an Idaho-based nonprofit that operates a network of 18 health clinics across three states, opted to cease providing gender-affirming care at all of its locations.

“Gender affirming-related diagnoses can be entered in patient charts. But those diagnoses cannot be addressed in any manner that could be construed as offering gender affirming care,” Health West’s chief medical officer told staff in an email, according to a copy of the message filed in court as part of the ongoing litigation against the law.

More states may soon see bans on public funding being used for gender-affirming care: So far this year, bills have been introduced in at least 10 states seeking to cut off the use of public funds for such care, according to The Associated Press.

In Georgia, for example, a bill currently being considered by the state legislature would ban spending state money on gender-affirming care through state employee health plans, Medicaid and prisons.

Khara Hayden, a trans woman and information technology specialist who works for the state, testified against the Georgia bill and said she might leave state employment if the measure passes.

“If you approve this bill, essentially you’re going to take away the care I need to continue living,” Hayden testified, saying a lack of hormone therapy would force her into early menopause.

Impact of Trump’s Trans Care Order

Although nothing in Trump’s executive order is enforceable, a number of hospitals across the U.S. — including NYU Langone, Children’s Hospital Los Angeles and Children’s National Hospital in Washington, D.C. — ceased providing some or all gender-affirming care to people under 19 after the order was issued. Some but not all facilities have since resumed providing care as a result of the restraining orders in place preventing the executive order from being enforced.

Lawrence Loe had his top surgery cancelled by NYU Langone just days before it was scheduled to occur, and is now a plaintiff in the ACLU lawsuit challenging the executive order. “I scheduled my surgery date for after I turned 18 in part to avoid potential restrictions on gender-affirming medical care for minors. I am angry and saddened that something like this could happen to me as an adult,” he wrote in an affidavit.

Seldin said this anticipatory compliance is not surprising.

“The executive orders create a climate of fear for trans folks and are meant to intimidate their health care providers into stopping care even when they are not legally required to,” Seldin told Truthout. “They also create a climate of permission for folks who oppose trans people’s existence.”

Transgender advocates fear the order’s ripple effects will affect a much broader swath of the trans population than those 18 and younger.

According to Casey at the Movement Advancement Project, once the Department of Health and Human Services begins reviewing Medicaid and Medicare coverage for people under 19, for example, it will have free rein to develop whatever policies it wants: “I would expect that the proposed regulations, when they come out, would likely have some kind of implication for adults.”

Health care institutions have also been preparing, including primary care clinics. A spokesperson for a health center in New England, who asked that the clinic not be named for fear of reprisal, said that their team was already discussing what to do if the public funds or Medicaid ban was extended to trans people of all ages. “That is a huge concern for us,” they told Truthout.

The spokesperson added that the most worrying aspect of Trump’s executive order is an instruction to review the “conditions of participation” for Medicare and Medicaid — a document that health care institutions must sign in order to participate in these programs. If the conditions of participation are revised, health care institutions may have to choose between agreeing not to provide gender-affirming care or forgo participating in the Medicaid or Medicare program altogether. Those programs are “hugely material to hospitals and other healthcare institutions” and generally essential to their solvency, said the spokesperson.

If the conditions of participation are revised and expanded to include people of any age, hormones would become more difficult to obtain, and gender-affirming surgery all but impossible.

In their fearful haste to comply with the order, hospitals are enacting the very outcome the new presidential administration wants.

Such changes could not be instituted overnight, lawyers told Truthout. If the proposed changes to Medicaid and Medicare survive legal challenges, they will still only be implemented after a years-long public comment and rule-making process. As a federal court recently ruled, it’s also likely unconstitutional for the Trump administration to unilaterally cease providing educational and research funds to health care institutions.

Still, the anticipatory compliance of hospitals in curtailing care to people under 19 indicates that some health care institutions can be pressured into ceasing access to life-saving care well before the legal or regulatory framework has changed.

Mounting Resistance

For now, civil rights attorneys and policy experts are urging state elected officials to take action, for example, by passing and enforcing shield laws to protect medical providers and creating state funds to cover financial losses faced by health care institutions for continuing to provide gender-affirming care.

Trans rights advocates can also pressure health care institutions to continue providing care in the face of the executive order, and call on hospital lobbying associations and pharmaceutical companies to do the same.

Some state attorneys general, including in New York and Massachusetts, have warned hospitals they will face anti-discrimination investigations if they cease providing gender-affirming care on the heels of the executive order.

In their fearful haste to comply with the order, hospitals are enacting the very outcome the new presidential administration wants, said Casey.

“The ambiguity and the vagueness of the executive order is on purpose,” Casey said. “Because that is the ultimate goal of the Trump administration: to make this care unavailable to anyone.”