Purpose: Initial rescissions of Executive Orders and Actions issued by President Biden.

Among these orders are several that addressed LGBTQ+ equity including “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (Executive Order 13988) and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (Executive Order 14075). The order establishing the White House Gender Policy Council (Executive Order 14020) and several Orders related to diversity, equity, and inclusion were also rescinded, as were orders related to nondiscrimination and equity in schools.

Implications: This order could lead to less oversight, reduced health programing, and fewer policies protecting LGBTQ+ people, which could negatively impact access to care and well-being. Of particular note:

• Rescinds orders that had called for LGBTQ+ people’s health equity, the national public health needs of LGBTQ+ people, LGBTQ+ data collection, and nondiscrimination protections, including in health care.

• Rescinds orders that had called for nondiscrimination protections for LGBTQ+ young people in school, which could contribute to stigma and worsened mental health.

Purpose: To define sex as an immutable binary biological classification and remove recognition of the concept of gender identity, including in sex protections and in agency operations. 

The order states that “It is the policy of the United States to recognize two sexes, male and female” and directs the Executive Branch to “enforce all sex-protective laws to promote this reality”. Elements of the order that may affect LGBTQ people’s health are as follows:

• Defines sex as “an individual’s immutable biological classification as either male or female.” States that “’sex’ is not a synonym for and does not include the concept of ‘gender identity’” and that gender identity “does not provide a meaningful basis for identification and cannot be recognized as a replacement for sex.”

• Defines male and female based on reproductive cell production. Introduces the term “gender ideology” which is defined to include  “the idea that there is a vast spectrum of genders that are disconnected from one’s sex” and “maintains that it is possible for a person to be born in the wrong sexed body.”

• Directs the Secretary of Health and Human Services (HHS) to provide the U.S. government, external partners, and the public guidance expanding on the sex-based definitions set forth in the order within 30 days.

• Directs each agency and all federal employees to “enforce laws governing sex-based rights, protections, opportunities, and accommodations to protect men and women as biologically distinct sexes,” including “when interpreting or applying statutes, regulations, or guidance and in all other official agency business, documents, and communications.”

• Directs each agency and all Federal employees, “when administering or enforcing sex-based distinctions,” to “use the term ‘sex’ and not ‘gender’ in all applicable Federal policies and documents.”

• Directs agencies to “remove all statements, policies, regulations, forms, communications, or other internal and external messages that promote or otherwise inculcate gender ideology, and shall cease issuing such statements, policies, regulations, forms, communications or other messages.”

• Directs agency forms to exclude gender identity and directs agencies to “take all necessary steps, as permitted by law, to end the Federal funding of gender ideology.”

• Requires that federal funds “not be used to promote gender ideology” and directs agencies to ensure “grant funds do not promote gender ideology.”

• Directs the Attorney General to ensure the Bureau of Prisons revises policies to prohibit federal funds from being expended “for any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite sex.”

• Rescinds multiple executive orders issued by President Biden, including: “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (13988), “Establishment of the White House Gender Policy Council” (14020) (which is also dissolved), and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (14075).

• Also directs agencies to rescind certain guidance documents, including, “The White House Toolkit on Transgender Equality”; “The Attorney General’s Memorandum of March 26, 2021 entitled “Application of Bostock v. Clayton County to Title IX of the Education Amendments of 1972,” and range of orders related to LGBTQ+ students in schools.

Implications: This order is broad, directed to all federal agencies and programs. Because federal health programs reach LGBTQ+ people, and some are specifically designed to be inclusive of the LGBTQ+ community, or account for gender identities in addition to biological sex, this Order could widely affect program funding, guidance, and access. It has several possible implications:

The terms used in the Order include several biological and social inaccuracies which could perpetuate misinformation about LGBTQ+ people and transgender people’s health needs. It also takes steps towards ban gender care in certain area, most explicitly in prisons.

Requiring that federal funds are not used to “promote gender ideology” has caused significant confusion. Since this order was issued, there have been multiple reports of HIV programs and community health centers that have lost funding as a result of supporting programs inclusive of transgender people. In addition, there have been reports that some health care facilities paused providing youth with gender affirming care, fearing that federal funding would be withheld according to this and another Order relating to youth access to gender affirming care (see separate entry). (See court decisions below.) Withholding care could lead to negative health outcomes for those that require it.

Data collection and data presentation/distribution have been impacted. At first some data was removed from federal websites, though due to court order this appears to have been restored. If public health messaging and services related to the health needs of transgender people, or other specific populations, are unavailable, this may result in adverse health outcomes such increased disease prevalence, greater difficulty with care engagement, and poor mental health outcomes. There have been reports that gender identity questions will be removed from federal surveys which makes tracking the experiences and well-being of LGBTQ+ people more difficult.

The order directs the HHS Secretary to take action to end gender affirming care through Section 1557 of the Affordable Care Act (ACA), the law’s major nondiscrimination provision, which includes protections on the basis of sex. While the Biden administration interpreted sex protections to include sexual orientation and gender identity, it is expected that the Trump administration will seek to remove these protections, as was the approach during his first term. Despite the Executive Orders and any future guidance, courts could continue to rule that such protections exist in statute.

On March 17^th the VA announced that it would phase out providing gender affirming care to comply with this Executive Order. Exceptions include Veterans already receiving hormone therapy from the VA or Veterans “receiving such care from the military as part of and upon their separation from military service” who are eligible for VA health care. The VA will not provide other gender affirming medical services.

The statement writes that historically the VA had provided a range of gender affirming services and “letters of support encouraging non-VA providers to perform sex-change surgeries on Veterans.” These services had been authorized under the now rescinded Veterans Health Administration Directive 1341(4).

There have been multiple legal challenges to this Order with some judicial actions that have paused aspects of implementation:

• On February 4, 2025 a lawsuit was filed in federal court challenging the Order on the grounds that it usurps Congressional  power, violates Sec. 1557 of the ACA, and is unconstitutional and on February 11 a temporary restraining order  and memorandum opinion was issued requiring restoration of webpages, datasets, and any other  resources needed to provide medical care, identified by the Plaintiffs.

• On February 4, 2025, a separate federal lawsuit was filed challenging this Order and the Executive Order on “Protecting Children from Chemical and Surgical Mutilation” (see separate entry), asserting they are openly discriminatory, unlawful, and unconstitutional. On February 13, a federal judge issued a temporary restraining order preventing the federal government from withholding or conditioning funding on the basis of providing this care.

• An additional suit was filed on February 19, 2025 by the National Urban League, National Fair Housing Alliance, and AIDS Foundation of Chicago challenging three Executive Orders: “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” as usurping the power of Congress, violating the Constitution and the Administrative Procedures Act, and, seeking declaratory and injunctive relief. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ+ communities and the programs that serve them.

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” Orders claiming they usurp the power of Congress and violate the Constitution. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9^th, 2026, the court issued a preliminary injunction, blocking in part key provisions in this EO and in the DEI EO including those that instruct agencies to remove and cease to issue  materials and “communications…that promote or otherwise inculcate gender ideology” and instructing agencies to “end the Federal funding of gender ideology”; prohibit federal funds from being “used to promote gender ideology,”; and direct agencies and departments to terminate DEI offices and positions, materials, initiatives, performance requirements, and grants or contracts.

• On March 12, 2025 two physician and academic plaintiffs filed a lawsuit challenging the Order and related OPM memo when their articles were removed from HHS’ Agency for Healthcare Research and Quality (AHRQ)’s Patient Safety Network (PSNet), a federal online patient-safety resource. The reason for the removal articles was for their inclusion of passing references to transgender patients. On May 23, a MA district court found the plaintiffs would likely succeed on their constitutional 1^st amendment claims and granted a preliminary injunction requiring HHS to republish the censored content.

Purpose: To limit diversity, equity, inclusion, and accessibility (DEIA) activities in government and by government contractors and grantees.  
 
Directs each agency, department, or commission head to take the following actions (among others):  
• terminate, to the maximum extent allowed by law, all DEI, DEIA, and “environmental justice” offices and positions…; all “equity action plans,” “equity” actions, initiatives, or programs, “equity-related” grants or contracts… 
• provide the Director of the OMB with a list of all “federal grantees who received Federal funding to provide or advance DEI, DEIA, or “environmental justice” programs, services, or activities since January 20, 2021,” among other actions.  

Implications: As with the other DEIA related Order (see separate entry), these efforts could make reaching populations with unique health needs in culturally competent ways more challenging, including in programs related to LGBTQ+ health and HIV. It could also jeopardized programs and funding for agencies reaching these communities.
There have been multiple legal challenges to this Order:

• On February 3, a lawsuit was filed by four diverse plaintiffs challenging the constitutionality of this Order and the Order, “Ending Illegal Discrimination and Restoring Merit-Based Opportunity”.

• An additional suit was filed in federal court on February 19, 2025 by the National Urban League, National Fair Housing Alliance, and AIDS Foundation of Chicago challenging this order as well as the “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” ” as usurping the power of Congress, violating the Constitution and the Administrative Procedures Act, and, seeking declaratory and injunctive relief. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them.

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” orders claiming they usurp the power of Congress and violate the Constitution.  In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9^th, 2026, the court issued a preliminary injunction, blocking in part key provisions in this EO and in the “gender ideology” EO including those that instruct agencies to remove and cease to issue  materials and “communications…that promote or otherwise inculcate gender ideology” and instructing agencies to “end the Federal funding of gender ideology”; prohibit federal funds from being “used to promote gender ideology,”; and direct agencies and departments to terminate DEI offices and positions, materials, initiatives, performance requirements, and grants or contracts.

Purpose: Order seeks to end federal “preferencing” through DEIA efforts within government and through contracting to the extent that they do not comply with the Administration’s view of civil rights law.

The order is broad and non-specific but includes the following directives:

• Orders all executive departments and agencies “to terminate all discriminatory and illegal preferences, mandates, policies, programs, activities, guidance, regulations, enforcement actions, consent orders, and requirements.  I further order all agencies to enforce our longstanding civil-rights laws and to combat illegal private-sector DEI preferences, mandates, policies, programs, and activities.”

• Orders agency heads to include in every contract or grant award “a term requiring the contractual counterparty or grant recipient to agree that its compliance in all respects with all applicable Federal anti-discrimination laws is material to the government’s payment decisions for purposes of section 3729(b)(4) of title 31, United States Code; and…A term requiring such counterparty or recipient to certify that it does not operate any programs promoting DEI that violate any applicable Federal anti-discrimination laws.”

Implications: As with the other DEIA related Order (see separate entry), these efforts could make reaching populations with unique health needs in culturally competent ways more challenging, including in programs related to LGBTQ+ health and HIV. It could also jeopardized programs and funding for agencies reaching these communities.

There have been multiple legal challenges to this Order:

• On February 3, a lawsuit was filed by four diverse plaintiffs challenging the constitutionality of this Order and the Order, “Ending Illegal Discrimination and Restoring Merit-Based Opportunity”.

• An additional suit was filed in federal court on February 19, 2025 by the National Urban League, National Fair Housing Alliance, and AIDS Foundation of Chicago challenging this order as well as the “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” ” as usurping the power of Congress, violating the Constitution and the Administrative Procedures Act, and, seeking declaratory and injunctive relief. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them.

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” orders claiming they usurp the power of Congress and violate the Constitution.  In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9^th, 2026, the court issued a preliminary injunction, blocking in part key provisions in this EO and in the “gender ideology” EO including those that instruct agencies to remove and cease to issue  materials and “communications…that promote or otherwise inculcate gender ideology” and instructing agencies to “end the Federal funding of gender ideology”; prohibit federal funds from being “used to promote gender ideology,”; and direct agencies and departments to terminate DEI offices and positions, materials, initiatives, performance requirements, and grants or contracts.

Purpose: Order directs agencies and programs to work towards significantly limiting access to gender affirming care for young people (defined as those under age 19) nationwide.

• Directs agencies to rescind and amend policies that rely on guidance from the World Professional Association for Transgender Health (WPATH).

• Directs the HHS Secretary to conduct and publish a review of existing literature and best practices related to gender affirming care and gender dysphoria and to “increase the quality of data to guide practices“ in this area.

• Directs executive department and agency heads “that provide research or education grants to medical institutions, including medical schools and hospitals”, “in coordination with the Director of the Office of Management and Budget” to “immediately take appropriate steps to ensure that institutions receiving Federal research or education grants end the chemical and surgical mutilation of children” (which is how the Order defines gender affirming care).

• Directs the HHS Secretary to take action to end gender affirming care for children “including [through] regulatory and sub-regulatory actions, which may involve the following laws, programs, issues, or documents:
– Medicare or Medicaid conditions of participation or conditions for coverage
– clinical-abuse or inappropriate-use assessments relevant to State Medicaid programs
– mandatory drug use reviews
– section 1557 of the Patient Protection and Affordable Care Actquality, safety, and oversight memoranda
– essential health benefits requirements; and
– the Eleventh Revision of the International Classification of Diseases and other federally funded manuals, including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.”

• Withdraws Biden Administration “HHS Notice and Guidance on Gender Affirming Care, Civil Rights and Patient Privacy” and directs the Secretary of HHS “in consultation with the Attorney General [to] issue new guidance protecting whistleblowers who take action related to ensuring compliance with this order.”

• Directs the Secretary of the Department of Defense to “commence a rulemaking or sub-regulatory action” restrict access to gender affirming care for children in the TRICARE program.

• Directs the Director of the Office of Personnel Management to limit access to care in coverage for federal employees’ families by requiring “provisions in the Federal Employee Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) programs call letter for the 2026 Plan Year” that would require eligible carriers to exclude “coverage for pediatric transgender surgeries or hormone treatments…”

• Directs the Attorney General to review Department of Justice laws on female genital mutilation and “prioritize enforcement of protections” and “to convene States’ Attorneys General and other law enforcement officers to coordinate the enforcement of laws against female genital mutilation.”

• Directs the Attorney General to “prioritize investigations and take appropriate action to end deception of consumers, fraud, and violations of the Food, Drug, and Cosmetic Act by any entity that may be misleading the public about long-term side effects of chemical and surgical mutilation.”

• Directs the Attorney General “in consultation with the Congress” “to draft, propose, and promote legislation to enact a private right of action for children and the parents” who have received gender affirming care “which should include a lengthy statute of limitations.

• Directs the Attorney General to “prioritize investigations and take appropriate action to end child-abusive practices by so-called sanctuary States that facilitate stripping custody from parents who support the healthy development of their own children, including by considering the application of the Parental Kidnapping Prevention Act and recognized constitutional rights.”

• Directs agency heads included in this executive order to “submit a single, combined report to the Assistant to the President for Domestic Policy, detailing progress in implementing this order and a timeline for future action” within 60 Days of its issuance.

Implications: If fully implemented, the Order would broadly and extensively limit access to gender affirming care for young people, across a range of payers and providers. Access to gender affirming care is associated with improved mental health outcomes for transgender people and limiting this care with negative ones, including poorer mental health outcomes. Additional impact includes:

• The executive order includes details about sex, gender identity, gender affirming care, and transgender people that conflict with science and evidence. These inaccuracies include suggesting that large shares of youth are seeking gender affirming medical care, that regret rates among those seeking care are high, and conflating “female genital mutilation” and gender-affirming care. This has the potential to promote hostility, stigma, and discrimination, and can lead to care denials.

• It seeks to remove Federal reference to one of the standards of evidence-based care for transgender people in the US. Directing the HHS Secretary to develop new guidance without this standard, and in accordance with this and other orders, could limit agency ability to identify standards that adequately meet the needs of transgender people.

• It also seeks to condition federal research and education grants on grantees not providing young people with gender affirming care.

• There has already been some confusion with certain states and providers looking to preemptively comply with the order and another Order relating to “gender ideology” (see separate entry).

• The order lays groundwork for the Administration remove explicit protects for LGBTQ+ people in health care, including with respect to accessing gender affirming care. Specifically, the Order suggests a reinterpretation of sex protections in Section. 1557 of the Affordable Care Act void of explicit protections on the basis of sexual orientation and gender identity.

• The order leans on laws and policies unrelated to gender affirming care in an effort to limit access to those services including by erroneously conflating gender affirming care and female genital mutilation, using the FDA regulatory process to limit access, and suggesting kidnapping protections be applied to parents in certain circumstance.

On January 31, 2025. FEHB issued a letter to carriers stating that begining plan year 2026, carriers should not covre surgical or hormonal gender affirming care.

On February 19, 2025, additional guidance was released relating to this order, providing new and refined definition of terms “ which directs the Department of Health and Human Services (the Department) to promulgate clear guidance to the U.S. Government, external partners, and the public, expanding on the sex-based definitions set forth in the Executive Order.”

On February 20, 2025, pursuant to this Order, HHS issued a “Recession of ‘HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy’ issued by the Biden Administration” which had stated the Administration “stands with transgender and gender nonconforming youth” and that medically necessary for gender affirming care for minors improves physical and mental health. It also reiterated that administration’s view that Sec. 1557 of the ACA includes protections on the basis of sexual orientation and gender identity.

There have been multiple legal challenges to this Order with some judicial actions that have paused aspects of implementation:

• On February 4, 2025, a federal lawsuit was filed challenging this Order and the Executive Order on “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to The Federal Government,” asserting they are openly discriminatory, unlawful, and unconstitutional. On February 13, a federal judge issued a temporary restraining order preventing the federal government from withholding or conditioning funding on the basis of providing this care. On March 4th, the court issued a preliminary temporary injunction.

• An additional federal lawsuit was filed on February 7^th challenging this executive order with a separate temporary restraining order being issued on the 14^th preventing the conditioning of federal funds and also applying to a condition linking gender affirming care to female genital mutilation. The restraining order was extended through March 5th on February 26th. 

• In March a class action lawsuit was filed in federal district court challenging the Bureau of Prisons (“BOP”) implemention of the order. In June a preliminary injunction blocking BOP officials from providing hormone therapy and accommodating transgender people was granted.

On June 1, the FBI posted on social media urging the public to “report tips of any hospitals, clinics, or practitioners performing these surgical procedures on children,” despite pediatric gender affirming care being permitted in about half of states and not prohibited by the federal government.

Purpose: Order seeks to end federal “preferencing” through DEIA efforts within government and through contracting to the extent that they do not comply with the Administration’s view of civil rights law.

The order is broad and non-specific but includes the following directives:

• Orders all executive departments and agencies “to terminate all discriminatory and illegal preferences, mandates, policies, programs, activities, guidance, regulations, enforcement actions, consent orders, and requirements.  I further order all agencies to enforce our longstanding civil-rights laws and to combat illegal private-sector DEI preferences, mandates, policies, programs, and activities.”

• Orders agency heads to include in every contract or grant award “a term requiring the contractual counterparty or grant recipient to agree that its compliance in all respects with all applicable Federal anti-discrimination laws is material to the government’s payment decisions for purposes of section 3729(b)(4) of title 31, United States Code; and…A term requiring such counterparty or recipient to certify that it does not operate any programs promoting DEI that violate any applicable Federal anti-discrimination laws.”

Implications: Should the federal government proceed with conditioning federal funding for schools on whether or not they support transgender students, it could exacerbate existing mental health disparities, contribute to stigma and discrimination, and reduce school connectedness. For example, the policies detailed in the Order could prevent schools from recognizing transgender students’ identities (e.g. their names and pronouns), allow schools to withhold mental health services, to out students to (potentially unsupportive) families, and to restrict facility use and activity participation.

Purpose: The memorandum seeks to “stop funding Nongovernmental Organizations that undermine the national interest and administration priorities.”

The memorandum states:

• It is Administration policy “to stop funding [Nongovernmental Organizations] NGOs that undermine the national interest.”

• Direct heads of executive departments and agencies to review all funding that agencies provide to NGOs and “to align future funding decisions with the interests of the United States and with the goals and priorities of my Administration, as expressed in executive actions; as otherwise determined in the judgment of the heads of agencies; and on the basis of applicable authorizing statutes, regulations, and terms.”

Implications: This memo aligns with other administrative efforts to stop current and future funding from being provided to NGOs that do not align with administrative priorities and could impact funding to health organizations or programs aimed at serving transgender people or research funding inclusive of trans and gender diverse people. It could also potentially impact care for LGBTQ+ people more broadly if services aimed directly at this population are considered DEIA efforts.

Purpose: “To notify the Court that the government’s previously stated views” on a case challenging a state’s ban on gender affirming care “no longer represents the United States’ position.”

• Notifies the Court that “following the change in Administration, the Department of Justice has reconsidered the United States’ position in” the case brought by the Biden Administration challenging Tennessee’s ban on gender affirming care for minors. The letter states, that their view is that the Tennessee law being challenged “does not deny equal protection on account of sex or any other characteristic,” which is the question before the Court.

• Despite this change in perspective, the Trump Administration encouraged the Court to resolve the questions presented without granting certiorari to the original plaintiffs.

Implications: There are 26 states with bans on gender affirming care for minors and litigation challenging these bans is ongoing. At the request of the Biden Administration, who brought the plaintiff’s case from the lower courts, the Supreme Court agreed to examine whether the Tennessee ban violates Equal Protection constitutional protections under the 14^th Amendment. The case was briefed and argued prior to the administration change. Upon taking office, the Trump Administration wrote this letter to the Court stating that the Biden Administration position no longer represented that of the U.S. government but nevertheless asked the court to decide the case. The court will likely issue a decision in the case and technically, the Trump Administration letter should not have bearing on the court’s decision. The court is expected to issue a decision in the case this summer (2025).

Purpose: To alert providers to the administration’s approach to children’s access to gender affirming care and serve as notice “that CMS may begin taking steps in the future to align policy, including CMS-regulated provider requirements and agreements…” to limit such care.

The memorandum states:

• That “CMS renews its commitment to promoting evidence-based standards through health quality and safety improvement activities, and reminds hospitals and other applicable facilities and providers of the obligation to prioritize the health and safety of their patients, especially children.” It questions evidence around gender affirming care for young people and states “CMS may begin taking steps in the future to adjust its policies to reflect this…”

Implications:

• The CMS memo aligns with policies put forward in the Executive Order, “Protecting Children From Chemical and Surgical Mutilation,” related to limiting young people’s access to gender affirming care, provisions of which are subject to a nationwide preliminary injunction (described in above entry). However, this is not explicitly stated in the memo.

• On March 6^th the Health Resources & Services Administration (HRSA) and Substance Abuse and Mental Health Services Administration (SAMHSA) released additional guidance stating that they would review policies, grants, and programs for consistency with the CMS memo (SAMHSA letter unavailable but described in this filing). HRSA also specifically notes the agency will review its Children’s Hospitals Graduate Medical Education (CHGME) Payment Program for consistency with the memo.

• While the memo does not specifically refer to the Executive Order, on March 7^th, plaintiffs in a case challenging the order sought enforcement of the preliminary injunction claiming that the CMS memo and HRSA/SAMHSA guidance violate its terms because by “threatening to withhold federal funding, the Executive Orders coerced hospitals into immediately shutting down gender affirming medical care for people under nineteen to avoid potential loss of funds.”

• Depending on how future policy is implemented, CMS could seek to significantly limit access to gender affirming care for young people.

Purpose: Issued to proclaim April as National Child Abuse Prevention Month. Describes “the sinister threat of gender ideology” as “one of the most prevalent forms of child abuse facing our country today.”

• Erroneously conflates youth access to gender affirming care with child abuse.
• References other efforts (see above) aimed at “prohibiting public schools from indoctrinating our children with transgender ideology” and “taking action to cut off all taxpayer funding to any institution that engages in the sexual mutilation of our youth.”
• Promises legal action against those perpetrating child abuse.

Implications: The proclamation includes details about gender affirming care and transgender people that conflict with science and evidence, including that children are being “indoctrinated” “with the devastating lie that they are trapped in the wrong body,” referring to gender affirming surgery (which is very rare among young people) as “sexual mutilation surgery,”  and suggesting that such care inhibits “happiness, health, and freedom,” for young people and creates “heartbreak” for parents and families.

• By erroneously conflating gender affirming care and abuse, potentially threatens those providing or facilitating access by stating, “we affirm that every perpetrator who inflicts violence on our children will be punished to the fullest extent of the law.”

Purpose: Reverses a Biden Administration policy that had permitted the Ryan White HIV/AIDS Program to cover certain gender affirming care services as a part of whole person care to transgender people with HIV.

• Referring to a policy on gender affirming care from the Biden administration, the letter states that “under the previous administration, certain interpretations of RWHAP’s allowable uses…co-opted the program’s patient centered mission in favor of radical ideological agendas and policies.”

• The letter further states “that RWHAP funds shall be marshaled exclusively toward evidence-based interventions proven to combat HIV, sustain viral suppression, and improve the quality of life for those living with the disease” and reaffirms the prohibition on funding services outside the scope of outpatient care, including “surgeries and inpatient care, irrespective of setting or anesthesia”

Implications:

• Previously, Ryan White funds were permitted to be used to support gender affirming care within core medical and support service categories, including through the provision of hormones via ADAP programs. Additionally, funds could be used to “provide behavioral and mental health services to clients experiencing gender dysphoria and social and emotional stress related to transgender discrimination, stigma, and rejection.” The policy under the prior Administration prohibited surgery, as does the new one, so that does not represent a change.

• Prohibiting use of funds to support certain gender affirming care services may make care engagement more challenging for transgender Ryan White clients. In some cases, gender affirming care may have helped to connect clients with HIV services and thus improve HIV outcomes.

Purpose: HHS issued this notice “to clarify the non-enforceability of certain language that was included in the preamble to—but not the regulatory text of” the final rule on Section 504, “titled ‘Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance.’ The clarification states that language in the preamble concerning gender dysphoria, which is not in the regulatory text, does not have the force or effect of law and cannot be enforced.

Implications:

• Section 504 prohibits recipients of federal funding, including publicly-subsidized health payers and health care providers who accept Medicare or Medicaid, from discriminating against people on the basis of disability. The Biden Administration’s final rule on Sec. 504 included in the preamble that HHS would “approach gender dysphoria as it would any other disorder or condition. If a disorder or condition affects one or more body systems, or is a mental or psychological disorder, it may be considered a physical or mental impairment.”

• This new interpretation could weaken certain protections for transgender and gender non-conforming people.

Purpose: “The purpose of this letter is to ensure that state Medicaid agencies are aware of growing evidence regarding certain procedures offered to children, and to remind states of their responsibility to ensure that Medicaid payments are consistent with quality of care and that covered services are provided in a manner consistent with the best interest of recipients.”

States that “medical interventions for gender dysphoria in children have proliferated” and that “several developed countries have recently diverged from the U.S. in the way they treat gender dysphoria in children.”

CMS reminds states of the following federal Medicaid requirements:

• Program “responsibility to ensure that payments are consistent with ‘efficiency, economy, and quality of care.’”

• Requirement for states to “provide such safeguards as may be necessary to ensure covered care and services are provided in a manner consistent with the best interests of recipients.”

• Prohibition on “federal funding for coverage of services whose purpose is to permanently render an individual incapable of reproducing. Federal financial participation (FFP) is strictly limited for procedures, treatments, or operations for the purpose of rendering an individual permanently incapable of reproducing and…prohibited for such procedures performed on a person under age 21.”

• Drug utilization review (DUR) program requirements “to assure that prescribed drugs are appropriate, medically necessary, and are not likely to result in adverse results.”
– CMS encourages “states to review their DUR programs to ensure alignment with current medical evidence and federal requirements, including the evidence outlined above.
– Notes that “additional guidance on DUR approaches is forthcoming.”

Implications:

• Letter appears to encourage states to take steps to limit gender affirming care for youth within their state Medicaid programs and suggests that not doing so could put them out of compliance with federal law. It does not immediately change policy.

• Letter misrepresents certain information about gender affirming care including its frequency and the approach in international settings.

• Letter leverages a law aimed at addressing discrimination/unwanted sterilizations among people with disabilities to limit gender affirming care.

• The letter could lead to changes in state policy-making or make providers and/or employers less likely to cover services which could ultimately lead to more limited access to GAC. 

• CMS issued a press release along with the letter. The letter stated “Medicaid dollars are not to be used for gender reassignment surgeries or hormone treatments in minors.”

Purpose: An internal Department of Justice (DOJ) memorandum seeks to implement, in part, an executive order aimed at limiting minor’s access to gender affirming care (GAC) (see above).

The memo is an internal document that was leaked. It is not law but provides guidance relating to an earlier executive order aimed at limiting minor access to gender affirming care (see above). The memo reportedly:

• The internal document was leaked and is not law but provides guidance relating to an earlier executive order aimed at limiting minor access to gender affirming care.

• Puts providers “on notice” that “it is a felony to perform, attempt to perform, or conspire to perform female genital mutilation (“FGM”*) on” minors and states that the FBI “alongside federal, state, and local partners, will pursue every legitimate lead on possible FGM cases.”

• States DOJ “will investigate and hold accountable medical providers and pharmaceutical companies that mislead the public about the long-term side effects of chemical and surgical mutilations.”

• Directs “investigations of any violations of the Food, Drug, and Cosmetic Act by manufacturers and distributors engaged in misbranding by making false claims about the…use of puberty blockers, sex hormones, or any other drug” in GAC.

• Directs “investigations under the False Claims Act of false claims submitted to federal health care programs for any non-covered services related to radical gender experimentation.” Gives example of prescribing puberty blockers to a minor for GAC but reporting the service as being for early onset puberty. States Department will work with whistleblowers “with knowledge of any such violations” under The False Claims Act.

• Following prior direction “that Department employees shall not rely on”… the World Professional Association for Transgender Health (WPATH)… “guidelines, and that they should withdraw all court filings” doing so, “expressly extend[s] that direction to all Department employees.” Directs department to “purge all…policies, memoranda, and publications and court filings based on WPATH guidelines.”

• Launches “the Attorney General’s Coalition Against Child Mutilation” to “partner with state attorneys general to identify leads, share intelligence, and build cases against…” providers “…violating federal or state laws banning female genital mutilation and other, related practices…[and] support the state-level prosecution of medical professionals who violate state laws “prohibiting gender affirming care.

• Instructs Office of Legislative Affairs to draft legislation “creating a private right of action for children and the parents of children” who have had gender affirming care with “a long statute of limitations and retroactive liability” and work with Congress “to bring this bill to President Trump.”

Implications:

• The memo directs action but is not law. It seeks to implement an executive order that is, in part, currently enjoined in court.

• The memo includes inaccuracies relating to gender identity, gender affirming care, and transgender people that conflict with science and evidence. These inaccuracies include suggesting that being transgender is a harmful medical condition, that large shares of youth are seeking gender affirming medical care, that regret rates among those seeking care are high, and conflating “female genital mutilation” and gender-affirming care. This has the potential to promote hostility, stigma, and discrimination, and can lead to care denials.

• Seeks to discredit WPATH’s widely relied on standard of care guidelines which providers look to deliver best practices gender affirming care and is regularly referenced by major medical associations including the American Psychological Association.

• While nothing in the memo prohibits provision of gender affirming care, its emphasis on litigation and enforcement of existing law that do not necessarily implicate this care, could have a chilling effect on providers.

Purpose: To develop an evidence review around pediatric gender affirming medical care as commissioned by the executive order on Protecting Children From Chemical and Surgical Mutilation (see above entry).

“This Review of evidence and best practices was commissioned pursuant to Executive Order 14187, signed on January 28, 2025. It is not a clinical practice guideline, and it does not issue legislative or policy recommendations. Rather, it seeks to provide the most accurate and current information available regarding the evidence base for the treatment of gender dysphoria in this population, the state of the relevant medical field in the United States, and the ethical considerations associated with the treatments offered. The Review is intended for policymakers, clinicians, therapists, medical organizations and, importantly, patients and their families.” Among the report’s findings:

• Report concludes that the quality of evidence on the effects of gender affirming intervention is low but also that evidence on harms is “sparse.”

• Cites “significant risks” of medical transition, departing from most medical associations and widely used guidelines in the U.S.

• In addition to a focus on medical intervention (e.g. surgery, puberty blockers, and hormones) report discusses role of psychotherapy in gender affirming care, supporting the use of psychotherapeutic approaches, including an approach termed “exploratory therapy”, which can include conversion therapy. Conversion therapy is a practice that seeks to change an individual’s sexual orientation or gender identity. These practices contrast with recommendations from major medical associations, which criticize conversion efforts for their lack evidence, ineffectiveness, and because they can cause harm. Additionally, many states ban these practices for the same reasons.

Implications:

• Review could be used as support for other actions the administration seeks to take (some described here) aimed at limiting minor access to gender affirming care. Outside experts, including from the American Academy of Pediatrics, have raised concerns that the “report misrepresents the current medical consensus and fails to reflect the realities of pediatric care.”

• With respect to therapeutic practices, it could shift how some practitioners approach gender affirming care or potentially provide support to those using conversion related approaches.

• The report could also fuel misinformation in other areas, particularly around regret rates (which the report states are high when they are actually very low) and the share of young people seeking a medical transition (which the report states is large, when the share is small).

On May 28, 2025, HHS sent a letter to an unspecified group of providers, state medical boards, and health risk managers urging providers to update treatment protocol to align with the review’s findings and avoid relying on the WPATH Standards of Care (which are seen by gender affirming care providers as valuable and trusted source of guidance.) The letter points to risk but not benefits of gender affirming medical care and highlights the report’s promotion of psychotherapy as an alternative to other medical care.

Purpose: The letter from the Center for Medicare and Medicaid Services (CMS) is directed at “select hospitals” providing minors with gender affirming care services including puberty blockers, hormones, and surgeries. The aim of the letter is to collect information on the delivery of these services and their associated costs and revenue. CMS states they are collecting this data to “ensure quality standards at institutions participating in the Medicare and Medicaid programs” and because “CMS has an obligation to be a good steward of taxpayer dollar.” 

In the letter CMS asks for information on the following within 30 days:
• consent protocols for children with gender dysphoria, including when parental consent is required
• changes to clinical practice guidelines and protocols in light of the HHS Review (see above entry)
• adverse events, particularly children who later look to detransition
billing codes utilized for gender affirming care
• facility and provider-level revenue and profit margins data related to these services

Implications: If facilities or providers believe HHS is excessively engaged in oversight of their practice of this area of medicine, it could have a chilling effect on willingness to provide these treatments. Depending on what the Administration does with data collected, this effort could represent a significant step in the administration’s aim to limit GAC for minors.

The effort to collect this level of information is likely burdensome for providers, particularly within a 30-day period.

The letter appears to stoke misinformation in its suggestion that there is a lack of parental involvement or consent in the practice of gender affirming care and that regret is a serious problem in this field.

It also appears to question the validity of using federal dollars to provide this care and possibly that delivering these services to minors is a significant cost-burden to the federal government. Because just a small share of the population is transgender, and not all trans people seek medical intervention, costs are likely very low.

Purpose: To rescind a bulletin from the Biden administration that provided state Medicaid programs with guidance on implementing optional sexual orientation and gender identity (SOGI) questions on their applications for coverage.

The Trump administration bulletin states that “CMS no longer intends to collect this information from state Medicaid and Children’s Health Insurance Program (CHIP) agencies as part of Transformed Medicaid Statistical Information System (T-MSIS) data submissions.”

Implications: Collection of SOGI health data plays a role in documenting the health experiences and status of LGBTQ+ people. Data collection can reveal disparities and gaps in access, which can, in turn, inform policy making to address these challenges. Without this data, addressing these disparities is more challenging. SOGI Data collection expanded under the Biden administration and has retracted under the Trump administration.

Purpose: The rule prohibits gender affirming care services from being covered as an Essential Health Benefit (EHB) in ACA plans.
CMS changes how ACA complaint individual and small group plans cover gender affirming care services, which the rule calls “coverage for sex-trait modification.”  Beginning plan year 2026, insurers are prohibited from covering gender affirming care as an essential health benefit (EHB).

Differing from the proposed rule, which offered no definition, HHS defines “sex-trait modification” services to mean “any pharmaceutical or surgical intervention that is provided for the purpose of attempting to align an individual’s physical appearance or body with an asserted identity that differs from the individual’s sex.”
If a state mandates coverage for gender affirming care, the state would be required to defray the cost.

The preamble to the rule clarifies that CMS finds that as non-EHB services, EHB non-discrimination in the ACA do not apply.

Implications: The aim of the final rule aligns with policies expressed in Executive Orders on gender and limiting access to gender affirming care (discussed above), though the agency states the rule does not rely on these orders or their enjoined sections. The agency writes that the purpose of the rule is to ensure that health plans meet the ACA’s “typicality requirement,” that is that EHBs be “equal to the scope of benefits provided under a typical employer plan.” The preamble to the rule discusses debate among commenters about whether inclusion of these services is typical.

The rule does not mean that plans cannot cover gender affirming care services but excluding certain services from coverage as EHBs means that enrollees would not be assured the same cost-sharing and benefit design protections as for services included in the EHB package. Costs accrued for gender affirming care would not be required to count towards deductibles or out-of-pocket maximums and would not be protected from annual or lifetime limits, increasing out-of-pocket liability. Additionally, the portion of premiums attributable to specified gender affirming services would not be eligible for premium tax credits or cost-sharing reductions for low- and moderate-income enrollees.

While CMS does not believe the impact will be significant, some commenters expressed concern that the policy change, particularly its near implementation date for 2026 plan year, could create challenges for issuers, which have already been engaged in (and some completed) rate setting for 2026. They also stated that change would require plans that cover gender affirming care outside of the EHB to complete the necessary backend activities (e.g. changes to claims and utilization management programs and policies) to implement the change, activities that could be more burdensome for smaller issuers.

While HHS states that this rule does not violate various statues (e.g. ACA’s nondiscrimination provisions at Sec. 1557 or typicality requirements, ADA’s Section 505 protections, constitutional equal protections, etc.) and disagrees with those who commented on the proposed rule that HHS lacks legal authority to make these policy changes, the rule could ultimately face legal challenges on these or other grounds.

Purpose: The Department announced it issued more than 20 subpoenas to doctors and clinics providing young people with medical gender affirming care, to investigate “healthcare fraud, false statements, and more.”

Implications: Multiple providers (at least 7) have sought to quash the subpoenas in court, most successfully. In April 2026, the DOJ sought assistance from a Texas court in enforcing a subpoena of Rhode Island Hospital. This marked the first time the department asked a court to compel compliance with their administrative subpoenas relating to gender affirming care. The court sided with DOJ ordering compliance. Rhode Island Hospital appealed to the 5^th Circuit and requested a stay but was denied. A Rhode Island district court was separately hearing a motion to quash by the Rhode Island Child Advocate. The hospital then asked to join that effort as an intervener which the court granted. On May 13, 2026, a Rhode Island district court quashed the subpoena and enjoined DOJ from “seeking, receiving, using, retaining, or disseminating any patient-identifying information or protected health information produced by RIH in response to Administrative Subpoena .”  (The court offered multiple explanations as to why it permitted the hospital to join and why it was issuing an order counter to that of the Texas court, including that Rhode Island Hospital was not given an opportunity to present its own position to the Texas court before it issued an order.) DOJ stated it would comply but appeal to the 1st Circuit.  Meanwhile the Texas court ordered RIH to produce the requested documents to the court for preservation to be held in camera (with DOJ having no access). Rhode Island Child Advocate asked the 1st Circuit for injuction but before that court denied the request, RIH told the Texas Court it would comply.

Separately, in May 2026, 11 families moved for a proposed class action in federal court in Maryland seeking to enjoin DOJ from enforcing subpoenas when it comes to their personal information.

The investigation further amplified the chilling effect other administrative actions (see above) have had on providers, leading some to close down their gender affirming care clinics or curtail practices.

Purpose: The Federal Trade Commission (FTC) issued a request for public comment on “how consumers may have been exposed to false or unsupported claims about ‘gender-affirming care’(GAC), especially as it relates to minors, and to gauge the harms consumers may be experiencing.”

Arguing that GAC has been subject to “potential deceptive or unfair practices involved in this type of medical care,” the agency “seeks to evaluate whether consumers (in particular, minors) have been harmed by GAC and whether medical professionals or others may have violated Sections 5 and 12 of the FTC Act by failing to disclose material risks associated with GAC or making false or unsubstantiated claims about the benefits or effectiveness of GAC.”

As discussed in the RFI, this action comes on the heels of a recent workshop the agency held on the same topic and the agency now seeks comment related to:

• Experiences of individuals and families seeking GAC, including on recommendations made by providers, whether providers described risks/benefits/effectiveness, and whether providers discussed the current policy environment and debates related to GAC, among other issues.

• Whether GAC was obtained and whether individuals experienced benefits/side effects/adverse events, among other issues.

• Detail related to whether providers “made false representations regarding the benefits or effectiveness.”

• Information related to providers making “false representations regarding the benefits or effectiveness” related to GAC

Implications: This activity is likely to have a chilling effect on provider willingness to offer GAC.

The RFI (and surrounding actions) also have the potential to promote misinformation around the risks and benefits of GAC and suggests that providers are using deceptive and unethical positions in delivering GAC on a significant scale, something that has not been demonstrated. Additionally, the RFI states that there is “widespread concern about the harms” related to GAC but does not acknowledge the broad clinical support GAC has as medically necessary treatment for gender dysphoria, including from major U.S. medical associations.

Purpose: The Executive Order seeks reform “the process of Federal grantmaking while ending offensive waste of tax dollars.”

The EO aims to overhaul the federal grantmaking and grant review process “to strengthen oversight and coordination of, and to streamline, agency grantmaking to address these problems, prevent them from recurring, and ensure greater accountability for use of public funds more broadly.”  One section of the EO requires agencies to “ensure that…[grants] are consistent with agency priorities and the national interest.” In addition to other actions, agencies are directed to ensure that awards are not “used to fund, promote, encourage, subsidize, or facilitate” certain themes including, “denial by the grant recipient of the sex binary in humans or the notion that sex is a chosen or mutable characteristic” and “racial preferences or other forms of racial discrimination by the grant recipient, including activities where race or intentional proxies for race will be used as a selection criterion for employment or program participation,” among others.

Implications: This approach to grantmaking could further chill research and grantmaking related to and aimed to supporting transgender and gender diverse people, including that related to health and healthcare. This could impact access to and availability of culturally competent services at the individual level and reduce research and data on transgender and gender diverse communities more broadly. Such research in turn could have been used to inform service delivery and policy making and to address health disparities.

Purpose: Building on an earlier carrier letter laying out criteria for coverage (see Jan. 28, 2025 entry), states that for Plan Year 2026, hormonal and surgical gender affirming care will not be covered under the Federal Employees Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) Programs for enrollees, regardless of age. Requires carriers to “establish an exceptions process…for enrollees who are mid-treatment.” Policy permits the same interventions for other medical indications.

Implications: Restricts adult coverage (building on previously restricted minors’ coverage) for gender affirming hormonal and surgical care under the FEHB and PSHB programs. Requires implementation of a case-by-case exceptions process for those receiving gender affirming care. This is a reversal of a 2015 policy that had prohibited carriers, as of plan year 2016, from having a “a general exclusion of services, drugs or supplies related to gender transition or sex transformations.”

Purpose: CDC updated its priorities statement on the agency’s “about” website to include discussion of gender affirming care, parental rights, and DEI (among a range of other topics) not previously included on the site.

With respect to gender affirming care, the agency refers to its “comprehensive review of the evidence and best practices for promoting the health of children and adolescents with gender dysphoria” (see above entry) and states it is  “a CDC priority to protect children from …” gender affirming care “and, to the extent allowable by applicable federal law and any relevant court orders, CDC programs will deprioritize programs that engage in these practices where permissible. CDC funds will also not support the costs of such practices where not required by the law or court order.” Further, CDC states it is an agency “priority to recognize that a person’s sex as either male or female is unchangeable and determined by objective biology, and to ensure CDC programs accurately reflect science, including the biological reality of sex.”

Another stated priority is that “CDC believes parents are the primary decision-makers in their children’s education and should have full authority over what their children are taught” and that school policies “and curricula should emphasize knowledge…without imposing ideas that may conflict with parents’ political, religious, or social beliefs.”
With respect to DEI the statement reads, “to the extent permitted by law, CDC will deprioritize diversity, equity, and inclusion (DEI) initiatives that prioritize group identity over individual merit” and that “CDC has previously invested substantially in ideologically-laden concepts like health equity—mainly on identifying and documenting worse health outcomes for minority populations.”

Implications: The new priorities statement represents are departure from the previous CDC “about” page which was much broader in its description and referenced the agency strategic plan stating that the plan “advances science and health equity and affirms the agency’s commitment to one unified vision— equitably protecting health, safety, and security.”

The new statement could potentially inform grant making and other agency activities such as reporting, recommendations/guidance, data collection, and data presentation. It may also impact CDC research ability to conduct research related to gender affirming care, transgender people, and health disparities. It also may limit the ability of grantees to use CDC resources to provide LGBTQ students with certain types of support or for the agency to provide resources to support LGBTQ youth. Targeting public health approaches to hard hit populations may be more difficult, including for conditions that disproportionately impact LGBTQ+ people, like HIV.

In its description of the HHS report findings on GAC, the CDC statement appears to go beyond what the review itself stated which was that the quality of evidence to support interventions was low and the evidence on harms was “sparse.” The CDC statement writes the review found that provision of gender affirming care to minors is “unsupported by the evidence and have an unfavorable risk/benefit profile.” Neither the report nor the CDC statement reference the well documented benefits associated with gender affirming care.

Purpose: The proposed rule wouldchange the hospital Conditions of Participation (CoPs) to prohibit most Medicare and Medicaid enrolled hospitals from providing specified gender affirming medical care for youth.

The proposal would prohibit most hospitals (i.e. those covered by section 42 CFR part 482) that accept payments from the Medicare or Medicaid programs (the majority of hospitals in the U.S.) from providing pharmaceutical and surgical services related to gender affirming care to young people under age 18. Prohibited services would include puberty blockers (which delay the onset of puberty), hormone therapy, and surgery (which is very rare among young people). While these services would be prohibited for the purposes of providing gender affirming care, the rule would permit hospitals to provide them to youth when the service is not intended to affirm a person’s gender.

The proposal does not take immediate effect. There is a 60-day comment period from the date of publication in the federal register.

Implications: The aim of the proposed rule aligns with earlier actions (e.g. the Executive Order aimed at limiting access to gender affirming care, letters from HHS to providers/states, etc. (discussed above)).

The  rule applies to facility type (not payer) and therefore, if adopted, would prohibit hospitals from offering gender affirming services to all patients under 18 years old regardless of payer, including youth with private insurance or other coverage and those paying cash, not just those covered by Medicare and Medicaid.

If finalized, the proposed rule would further limit access to gender affirming care nationwide. To the extent that academic research hospitals discontinue provision of care, this could also have implications for research being conducted in these institutions.

See KFF’s overview of this proposed rule: https://www.kff.org/lgbtq/new-trump-administration-proposals-would-further-limit-gender-affirming-care-for-young-people-by-restricting-providers-and-reducing-coverage/

Purpose: The proposed rule would prohibit the use of federal Medicaid of CHIP funds from covering pharmaceutical and surgical gender affirming services for young people (under age 18 for those covered by Medicaid and under age 19 for those covered by CHIP). Prohibited services would include puberty blockers (which delay the onset of puberty), hormone therapy, and surgery (which is very rare among young people). Federal funds would be permitted to cover the same services when the service is not intended to affirm a person’s gender. Under the proposal, states would be permitted to use state-only funds to cover the prohibited services.

The proposal does not take immediate effect. There is a 60-day comment period from the date of publication in the federal register.

Implications: The aim of the proposed rule aligns with earlier actions (e.g. the Executive Order aimed at limiting access to gender affirming care, letters from HHS to providers/states, etc. (discussed above)).
The rule applies to federal Medicaid as a payer and therefore restrict reimbursement for care regardless of provider type (e.g. hospitals, primary care providers, endocrinologists, etc.). However, it does not prohibit providers from offering these services
If finalized, the proposed rule would further limit access to gender affirming care nationwide and impact families with lower incomes the hardest. While young people with Medicaid and CHIP coverage could theoretically seek care outside of hospitals without using their insurance, the cost of doing so would likely be prohibitive.
See KFF’s overview of this proposed rule: https://www.kff.org/lgbtq/new-trump-administration-proposals-would-further-limit-gender-affirming-care-for-young-people-by-restricting-providers-and-reducing-coverage/

Purpose: The proposed rule seeks to amend federal regulations implementing Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination on the basis of disability in federal and federally funded programs, as it applies to recipients of funding from the Department of Health and Human Services (HHS). It would revise a Biden Administration final rule which, in the preamble, stated that HHS would be willing to view gender dysphoria as covered by Sec. 504 “as it would any other disorder or condition. If a disorder or condition affects one or more body systems, or is a mental or psychological disorder, it may be considered a physical or mental impairment.” The proposed rule would do the opposite, and clarified that the current administration interprets statutory exclusions related to ‘‘gender identity disorders not resulting from physical impairments’’ to encompass ‘‘gender dysphoria not resulting from a physical impairment.’’

The proposal does not take immediate effect. There is a 30-day comment period from the date of publication in the federal register.

Implications: This new interpretation could weaken certain protections for transgender and gender non-conforming people.
(See related April 11, 2025 Notice above.)

Purpose: HHS Sec. Kennedy issued a declaration stating certain gender affirming care procedures are “neither safe nor effective as a treatment modality for gender dysphoria, gender incongruence, or other related disorders in minors, and therefore, fail to meet professional recognized standards of health care.” It further stated that “the Secretary ‘may’ exclude individuals or entities from participation in any Federal health care program if the Secretary determines the individual or entity has” delivered services that fail “to meet professionally recognized standards of health care.” However, HHS notes the “declaration does not constitute a determination that any individual or entity should be excluded from participation in any Federal health care program.”

Implications: The declaration was issued on the same day that proposed rules aiming to restrict youth access to gender affirming care in the Medicaid program and by hospitals participating in Medicare and Medicaid were released. (See more on the proposed rules in a separate entry below).

The declaration seeks to discredit widely used U.S. standards of care for gender affirming care (i.e. WPATH and Endocrine Society guidelines) and recommendations by major medical associations, instead relying on HHS’s evidence review relating to gender affirming care for minors (see above entry).  It seeks to develop a Secretary-defined standard that would instead find that certain gender affirming services fail to meet professional recognized standards of care and therefore provide a basis for HHS to restrict federal funding to providers offering this care. This diverges from current recommendations which support access to this care and deem it a medical necessity.

While the declaration states that it does not determine that specific individuals or entities “should be excluded from participation in any Federal health care program” and that “any such determination…[would be]…subject to further administrative and judicial review,” it represents an additional effort aimed at restricting federal funding from reimbursing for gender affirming care for minors. As with other efforts, the declaration excepts the same services used in gender affirming care for other medical purposes.

Should the declaration be further implemented, it could increase the limitations on youth access to gender affirming care. The declaration is not limited to payer (as the Medicaid proposed rule is) or to a specific facility type (as the Conditions of Participation rule is). It could apply to any provider receiving federal funds. Even if the declaration is not implemented, it could stoke additional fear among providers who may choose to continue to or newly stop offering these services out of retaliatory fear.

On December 24, 2025, a lawsuit was filed in which 20 states challenged the administration’s authority to issue the declaration, claiming it violates the Administrative Procedures Act and the Medicare and Medicaid statutes and that “the Secretary has no legal authority to substantively alter the standards of care and effectively ban, by fiat, an entire category of healthcare.” In March 2026, a federal judge issued a ruling from the bench finding that HHS had overstepped its authority, offering relief for the (now 21) plaintiff states. In April, the written order from the court was published. The court granted summary judgment in favor of the plaintiffs and vacated HHS’ declaration. The court found that “defendants lack the authority to unilaterally establish standards of care that supersede professionally recognized standards of care for provision of gender-affirming care…[and] lack the authority to exclude providers from federal healthcare programs based on their provision of gender-affirming care.”  The court further enjoined HHS from enforcing or implementing the declaration against providers in the Plaintiff States.

HHS has since referred mulitple providers to the Office of Inspector General based on the declaration.

Purpose: To “inform healthcare providers, families, and policymakers about evidence-based approaches to caring for children and adolescents experiencing gender dysphoria.”

It reviews findings from the HHS review of gender affirming care for youth (see above entry) and summarizes elements of other reviews before recommending that providers refuse to provide pharmaceutical and surgical gender affirming care for young patients, prioritizing instead psychosocial assessment and care. It also recommends providers share with families the administration’s view that there is “weak evidence for medical interventions” and “substantial documented harms” in medically treating gender dysphoria in young people.

Implications: The recommendations made are not binding but add to administrative efforts to reduce access to gender affirming care for young people. They ignore widely recognized benefits associated with gender affirming care access and recommendations of dominant US medical associations and guidelines.

Purpose: To issue warning letters to retailers and manufacturers of chest binders which include marketing language about their use to help alleviate gender dysphoria. The FDA letters, issued to 12 retailers and manufacturers,  state the binders are “misbranded” and that they are medical devices that must be registered with the FDA. In a press release HHS wrote “Breast binders are Class 1 medical devices used for purposes such as assistance in recovery from cancer-related mastectomy.” 

FDA states that these companies “should take prompt action to address any violations identified in this letter. Failure to adequately address this matter may result in regulatory action being initiated by the FDA without further notice.  These actions include, but are not limited to, seizure and injunction.” FDA states “if you believe that your products are not in violation of the FD&C Act, include your reasoning and any supporting information for our consideration as part of your response.”

Implications: The FDA efforts could create financial and logistical challenges for retailers and manufactures of chest binders used by transgender and nonbinary people. These challenges could result in access challenges for consumers, such as those relating to supply and cost.

Purpose: “To establish professional guidelines for the mental health evaluation and treatment of inmates meeting the diagnostic criteria’ for Gender Dysphoria (GD) to assist their progress toward recovery, while reducing or eliminating the frequency and severity of symptoms and associated negative outcomes.” Restricts the Bureau of Prisons (BOP) from providing surgical and hormonal medical services related to gender affirming care and offering accommodations. Specifically, the guidance:

• Prioritizes mental health care in the treatment of gender dysphoria, emphasizing assessment of comorbid psychiatric conditions, and collection of past medical records.
• Connects guidance to the gender ideology Executive Order (described in above entry) which “prohibits the Bureau from expending federal funds for ‘any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite sex’” unless prohibited by court order. While referencing the Executive Order, it also states that the policy is being adopted independent of the Order.
• States that treatment plans should be individualized and address all identified medical and psychiatric concerns but prohibits BOP from providing gender affirming surgeries and hormone therapy for those not currently receiving hormones.
• Requires a “rapid discontinuation” tapering plan for those already but recently receiving hormones as a part of gender affirming care and an “appropriately paced” discontinuation plan for those who have received hormones for “extended periods.” States that for those who have had gender affirming surgeries and have been on hormones for an extended period, “it may not be appropriate…for the initial tapering plan to include cessation of hormones. But tapering plans should be reevaluated regularly.”
• Prohibits BOP from providing (and says BOP may confiscate items related to) “social accommodation,” defined to include clothing, cosmetics, and other items like binders to help an inmate’s appearance align with their gender identity.

Implications:

• Marks an area where federal restrictions around gender affirming care extend to adults.
• Suggests that GD may be the result of, and addressed by, treatment of comorbid psychiatric conditions and prioritizes mental health interventions to the exclusion of other medical interventions that are widely considered best practice and not seen as interchangeable. As such, the policy could stand to negatively impact the well-being of transgender and nonbinary inmates in federal prisons seeking medically necessary gender affirming care. In addition, unwanted physical and emotional symptoms can occur because of hormone discontinuation.
• By restricting and/or confiscating “social accommodation” this policy puts up barriers to social transition and goes beyond medical restrictions.
• Uses the definitions section to reject the existence of transgender people’s identities stating that gender identity “does not provide a meaningful basis for identification.”
• The Gender Ideology Executive Order is being challenged in court, parts of which are subject to preliminary injunctions. This includes a case in which a federal judge temporarily enjoined federal prisons from withholding gender affirming care from inmates as a result of the order. It is yet to be seen how the new policy will intersect with the existing injunction but the judge has ordered the administrative record for the BOP policy be filed with the court.  

Purpose: FTC issued three CIDs to the American Academy of Pediatrics (see Exhibit 1), Endocrine Society (see Exhibit 1), and WPATH (see Exhibit 1) to investigate whether these organizations “has made, or assisted others in making, false or unsubstantiated representations or engaged in unfair practices in connection with the marketing and advertising of Pediatric Gender Dysphoria Treatment (PGDT)—medical interventions for minors with gender dysphoria, including but not limited to pubertal suppression, hormone therapy, and surgery.”

Implications: These actions could lead to the false impression that these medical organizations are engaged in marketing practices, delivery of goods/services (and specifically “unfair” ones) related to gender affirming care. These actions could further intensify the chilling effect other administrative actions have already had on provider willingness to offer gender affirming care to minors.

Purpose: U.S. Office of Personnel Management’s (OPM) carrier letter further laying out criteria for coverage for the Federal Employees Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) Programs. Builds on two earlier policies (see details on Jan. 2025 and Aug. 2025 policies above) stating that “Beginning in the 2027 Plan Year, Carriers must remove any exceptions process…for coverage of excluded services for members who are mid-treatment within a surgical and/or hormonal regimen for diagnosed gender dysphoria.” Counseling services for possible or diagnosed gender dysphoria must still be covered. Covered counseling services must be provided by a licensed mental health provider.

Implications: In 2025, the administration restricted coverage for gender affirming care for those enrolled in insurance through the FEHBP and PSHB programs but required carriers to have an exceptions process in place for those already receiving services. The new policy further restricts access by removing the exceptions process, further limiting coverage.

Purpose: On May 11, 2026, NYU Langone Hospital publicly announced that it and other health care institutions had received a grand jury subpoena from the U.S. Attorney’s office in the Northern District of Texas. Accompanying the subpoena was a demand for document production for the 2020-2026 time period.

NYU made the subpoena public on May 13, 2026. The documents requested are sweeping in nature ranging from personnel files of those associated with provision of or billing for gender affirming care, billing records and documentation policies, communications and materials with pharmaceutical companies regarding gender affirming care, the identities of and detailed medical information on patients seen for gender affirming care, communications related to off-label use of hormones, communications with WPATH, among other types of information. The subpoena requests that the produced materials be sent to the FDA Office of Criminal Investigations in the Kansas field office. Documents are requested from the hospital and a range of associated entities.

It is not known what other institutions received subpoenas and whether they received the same document request. It is also not known why the subpoena came out of the Northern District of Texas but notably, this is where the DOJ had earlier sought Rhode Island Hospital compliance with an administrative subpoena (see below and separate entry.)

Implications: A grand jury summons suggests a criminal investigation as does the direction to turn requested documents over to the FDA’s Office of Criminal Investigation. It could indicate that the government is pursuing claims under the Food Drug and Cosmetic Act, which the administration previously sought to use in efforts to enforce a subpoena in court against Rhode Island Hospital and also in the Northern District of Texas case (discussed above in separate entry). This is widely seen as an escalation in oversight compared to the previous DOJ subpoenas which were administrative in nature.

Grand jury subpoenas are likely to add to the escalating chilling effect administrative actions have had on providers of gender affirming care.

Purpose: The DOJ announced a resolution with Texas Children’s Hospital (TCH) as part of its “ongoing national investigation into violations of federal law in connection with the provision of” gender affirming care. TCH “entered into agreements with the Department and the Texas Attorney General that include commitments” not to provide young people with gender affirming medical care (which is already banned in Texas) and “pay over $10 million in damages and civil penalties” related to “false billing” allegations under the “Federal Food, Drug, and Cosmetic Act, the False Claims Act, and federal fraud and conspiracy laws.” TCH also agreed to establish a clinic dedicated to providing detransition-related services.The DOJ notes “The claims resolved by the United States in the settlements are allegations only and there has been no determination of liability. Both entities have denied all allegations.”

Implications: Because Texas already prohibits the provision medical gender affirming care for young people, the settlement does not change access to services in the state. The action, however, promotes misinformation related to gender affirming care, calling it a “destructive and discredited practice.” In fact, it is recommended for the treatment of gender dysphoria by major medical groups. Additionally, the creation of a “detransition clinic” could imply that detransitioning is widespread, which it is not, and that it warrants a specialized clinical environment.

Separately, the Texas AG, Ken Paxton, issued his own press release with similar content to the one issued by DOJ. However, it additionally notes that multiple providers were terminated and had their privileges removed. The AG’s release also noted that the settlement had been reached in coordination with the DOJ. 

The terminations and revocation of privileges will likely add to the chilling effect already characterizing the treatment of hospitals and providers when it comes to these services. Notably, these actions appear to penalize providers for provision of care occurring several years ago, before it was prohibited in the state.

While the DOJ release states that TCH had not been determined to be liable and had denied all allegations, reputational damage may still occur for the health care institution and some may perceive any provision of gender affirming care as in violation of federal law. The state AG’s release made no such disclaimer.  

In a press statement that has since been removed from their website, TCH, wrote that throughout the process with the DOJ and Texas AG they have been “navigating an unconscionable campaign of mistruths and mischaracterizations related to gender affirming care.” The institution writes they have been compliant with all laws and is “settling to protect our resources from endless and costly litigation”