Comments From Richard Besser, MD, on the HHS Proposed Rule to Prohibit Coverage of Gender-Affirming Care for Minors Under Medicaid and CHIP

The following comments were submitted by Richard Besser, MD, Robert Wood Johnson Foundation (hereinafter “RWJF” or “the Foundation”) President and CEO, in response to the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) Proposed Rule on Prohibition on Federal Medicaid and Children’s Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children (hereinafter “the Proposed Rule”), published in the Federal Register on December 19, 2025.

RWJF is a leading national philanthropy dedicated to taking bold leaps to transform health in our lifetime. Through funding, convening, advocacy, and evidence-building, we work side-by-side with communities, practitioners, and institutions to get to health equity faster and pave the way together to a future where health is no longer a privilege, but a right. Our comments are grounded in the perspectives and expertise of our grantees, who include organizations seeking to ensure that everyone has access to quality healthcare and health services.

RWJF strongly opposes the proposal to prohibit coverage of certain gender-affirming services for individuals with gender dysphoria under the Medicaid program and Children’s Health Insurance Program (CHIP) for several reasons further explained below. First, in support for the Proposed Rule, HHS cites several studies and evidence that are either flawed or discredited, or do not support the assertion that gender-affirming care is unsafe or ineffective, including cherry-picked evidence from several European countries. Second, gender-affirming care is medically necessary for individuals with gender dysphoria and a ban on coverage of services will harm individuals with low-income who need care. Third, HHS has no legal authority to promulgate the Proposed Rule prohibiting states from covering certain gender-affirming care services under the Medicaid program.

I.               The Proposed Rule Uses Flawed Evidence to Discredit the Safety and Effectiveness of Gender-Affirming Care

a.    The HHS Review is flawed

HHS relies extensively on its own review of treatments for gender dysphoria (HHS Review) to reach the conclusion that it may stop paying for the services at issue with Medicaid and CHIP funds.¹ But the HHS Review is deeply flawed.² It has been heavily criticized by major U.S. medical groups, including the American Medical Association (AMA), the American Academy of Pediatrics (AAP), the American Psychological Association (APA), and the American Academy of Child and Adolescent Psychiatry (AACAP).³ The HHS Review violates scientific norms, misrepresents scientific evidence, mischaracterizes gender identity in youth, and mischaracterizes the standard of care that incorporates gender-affirming care, all based on political motivation.⁴ As the American Psychiatric Association stated in its peer review of the HHS Review: “The Report fails to clearly articulate how the studies were selected, what criteria governed their inclusion or exclusion, or how their quality was assessed.”⁵ Another peer review by endocrinologist Richard J. Santen noted that the HHS Review was “stacked with members with an intellectual conflict of interest.”⁶

In the HHS Review, HHS purports to conclude that there is not enough evidence of the benefit of gender-affirming care for treating youth who are experiencing gender dysphoria and raises concerns about the long-term effects of gender-affirming care. The HHS Review, however, ignores the many studies that have found gender-affirming care to be safe and effective for treating gender dysphoria. For example, Cornell University’s “What We Know Project” compiled a systematic literature review of all peer-reviewed articles published in English between 1991 and 2017 that evaluated the effect of gender transition on transgender wellbeing. In 93% of the 55 primary research studies, gender transition had improved the overall wellbeing of transgender people. The Cornell review found no studies concluding that gender transition causes overall harm.⁷

More recently, the University of Utah College of Pharmacy’s Drug Regimen Review Center (DRRC) conducted a comprehensive two-year systematic review that found that hormone therapy is safe and effective for transgender youth.⁸ This review specifically analyzed studies that reviewed the physical outcomes of hormone therapy such as hormone levels, bone changes, blood pressure, growth, and body composition. The review found that, in terms of safety outcomes, any patient-level changes are minimal and that the average patient’s values remain in normal non-pathological ranges. The DRRC notes that, while none of the hormonal treatments are approved by the FDA for transition-related care, these treatments have been approved for treating a myriad of other conditions in minors and adults, such as breast cancer treatment, prostate cancer, endometriosis, and menopause.⁹ That means that these hormonal treatments have been proven to be safe by the FDA.¹⁰ In fact, the Utah DRRC report found significant evidence regarding the effectiveness of gender-affirming services in treating gender dysphoria among youth.¹¹ HHS’s assertion that these medications are unsafe to treat gender dysphoria is not consistent with the evidence.

b.    HHS mischaracterizes the evidence to support its foregone conclusion that gender-affirming care is harmful

HHS states that the proposed funding ban is justified by “evidence pointing to significant risks associated with the use of these procedures, including irreversible harms such as infertility.”¹² Putting aside the fact that the vast majority of the services at issue do not cause infertility, HHS’s reasoning is arbitrary, since Medicaid and CHIP funding is used to pay for a wide range of pediatric services that are associated with risks comparable to those associated with the services at issue here.

Many interventions are routinely provided, and paid for by Medicaid and CHIP, to treat children and youth even when they are associated with significant risks, including risks of irreversible harm and adverse outcomes. Moreover, under the Proposed Rule, Medicaid and CHIP funding will continue to pay for the same services when they are used to treat conditions other than gender dysphoria, despite the fact that similar risks could apply. For example, Medicaid and CHIP pay for puberty blockers when prescribed to treat central precocious puberty. Yet when used for this purpose, these medications carry the same risks as when they are used to treat gender dysphoria.¹³

While HHS highlights a generalized finding about the potential risks from international studies, the conclusion in the studies is significantly more nuanced. The Swedish Ludvigsson et al. study HHS cites concludes that the long-term effects of gender-affirming care could not be evaluated because the few longitudinal observational studies were hampered by a small number of participants and high attrition rates. The study further concludes that “evidence to assess the effects of hormone treatment…in children with gender dysphoria is insufficient.”¹⁴ While that conclusion is inconsistent with the many studies finding conclusive evidence of the effectiveness of hormone treatment in minors, it certainly does not amount to evidence that “the risks outweigh the benefits,” as HHS implies, and cannot justify a ban on coverage of gender-affirming services.

c.     HHS also misrepresents the state of coverage of gender-affirming care for youth in other countries

In addition to cherry-picking and misinterpreting studies related to gender-affirming care, HHS discusses extensively the experience of several European countries to justify the Proposed Rule. HHS cites studies commissioned by Sweden, Finland, and the United Kingdom as evidence that “the risk of medicalization may outweigh the benefits for children and adolescents with gender dysphoria.” There are several problems with HHS’s reasoning.

First, several of the international studies HHS highlights have been called into question, particularly for arriving at contradictory conclusions and for ignoring widespread evidence from other studies. For example, HHS emphasized the Cass et al., report from the United Kingdom in support of the Proposed Rule, while ignoring the vast criticism the report has received.¹⁵ Researchers and experts from Australia have commented on the Cass report:

The Cass Review's internal contradictions are striking. It acknowledged that some trans young people benefit from puberty suppression, but its recommendations have made this currently inaccessible to all. It found no evidence that psychological treatments improve gender dysphoria, yet recommended expanding their provision. It found that NHS provision of [gender-affirming medical treatment] (GnRHa, oestrogen or testosterone) was already very restricted, and that young people were distressed by lack of access to treatment, yet it recommended increased barriers to oestrogen and testosterone for any trans adolescents aged under 18 years. It dismissed the evidence of benefit from [gender-affirming medical treatment] as “weak”, but emphasised speculative harms based on weaker evidence. The harms of withholding [gender-affirming medical treatment] were not evaluated. The Review disregarded studies observing that adolescents who requested but were unable to access [gender-affirming medical treatment] had poorer mental health compared with those who could access [gender-affirming medical treatment]. Despite finding that detransition and regret appear uncommon, the Review's recommendations appear to have the goal of preventing regret at any cost.¹⁶ (emphasis added)

Second, while it is true that some European countries have tightened restrictions around access to some gender-affirming services for minors, the Proposed Rule would go far beyond the actions taken by these countries. For example, while Sweden updated its guidelines in 2022 to limit access to gender-affirming care for minors, these guidelines are recommendations only and do not have the overarching impact that the Proposed Rule would have in the U.S. As HHS recognizes, Sweden’s public healthcare system still covers gender-affirming care when medically necessary for a particular individual.¹⁷ In contrast, the Proposed Rule would completely eliminate federal Medicaid and CHIP coverage of the specified gender-affirming services for youth. As opposed to Sweden’s guidelines, the Proposed Rule effectively strips the authority to make final clinical decisions from medical providers.

Similarly, as HHS acknowledges, Norway has not taken any concrete action that would restrict access to gender-affirming care for minors, despite some recommendations from the Norwegian Commission for the Investigation of Health Care Services (UKOM).¹⁸ There are no indications that Norway is planning to ban coverage of these services for minors under any circumstance.

Finally, HHS conveniently highlights a handful of countries where gender-affirming care for minors has been restricted in some ways while ignoring other similarly situated countries that provide widespread coverage for gender-affirming care for minors based on medical necessity. Some of those countries that provide widespread coverage for gender-affirming care for minors include Austria, France, Germany, Iceland, New Zealand, Portugal, and Switzerland.¹⁹ The evidence is clear: While some countries have proposed or established guidelines to restrict access to gender-affirming services for minors based on lack of evidence or political motivation, the vast majority of similarly situated jurisdictions support unrestricted access to services at least on a case-by-case basis. HHS identifies a “growing international concern” about the use of some treatments in minors but unjustifiably ignores the vast consensus in other parts of the world.

II.             The Evidence Clearly Demonstrates that the Services at Issue are Clinically Appropriate to Treat Gender Dysphoria

Gender-affirming care is safe, effective, drastically improves health outcomes, and saves lives of children and youth. Research confirms that access to gender-affirming care significantly reduces depression and suicidality in transgender youth.²⁰ The Utah DRRC report discussed above found significant evidence regarding the effectiveness of gender-affirming services in treating gender dysphoria among youth. The study concluded:

[T]he consensus of the evidence supports that the treatments are effective in terms of mental health, psychosocial outcomes, and the induction of body changes consistent with the affirmed gender in pediatric [gender dysphoria] patients. The evidence also supports that the treatments are safe in terms of changes to bone density, cardiovascular risk factors, metabolic changes, and cancer. […] it is our expert opinion that policies to prevent access to and use of [gender-affirming hormone treatment] for treatment of [gender dysphoria] in pediatric patients cannot be justified based on the quantity or quality of medical science findings or concerns about potential regret in the future, and that high-quality guidelines are available to guide qualified providers in treating pediatric patients who meet diagnostic criteria.²¹

These findings are consistent with the overwhelming scientific and clinical evidence, which agrees that the services are safe and effective to treat gender dysphoria. This conclusion applies to all services at issue.²² For instance, in February 2024, the American Psychological Association released a statement affirming that policies that restrict coverage of gender-affirming services, such as the one in the Proposed Rule, “pose a direct threat to the mental health and emotional well-being of transgender, gender-diverse, and nonbinary youth, exacerbating the already high rates of depression, anxiety, and suicide attempts among this vulnerable population.”²³ Similarly, the American Academy of Pediatrics has repeatedly opposed laws or regulations that limit pediatricians’ ability to provider gender-affirming care that they have determined to be clinically appropriate for their patients.²⁴ The American Academy of Child and Adolescent Psychiatry has also expressed unequivocally that all children and adolescents should “have access to multi-disciplinary, evidence-based, and trauma-informed gender affirming health care.”²⁵ The fact that these major professional organizations with expertise on pediatric and psychological care have expressed support for all gender-affirming services is evidence of the widespread agreement that exists regarding the effectiveness of these services.

III.            A Ban on Medicaid and CHIP Coverage would Severely Harm Individuals with Gender Dysphoria

There is ample evidence that ending federal Medicaid and CHIP funding for the services at issue will create significant harm. Debating the humanity of transgender people, especially children, adversely impacts their mental and physical health, as well as that of their families.²⁶ Even prior to the increase in state bans on gender-affirming care in 2020, transgender students reported attempting suicide at rates far surpassing their non-transgender peers.²⁷ Research consistently shows that transgender youth experience higher levels of violence or threats of violence than non-transgender students.²⁸ Transgender youth also experience rejection from their families and support systems because of their gender identity at higher rates than non-transgender youth.²⁹ When young people are subjected to accumulated stressors—including national campaigns debating the legitimacy of transgender identity as mere “ideology” and dishonest rhetoric describing the care that allows them to thrive and live healthy lives with dehumanizing and incendiary language—they experience heightened mental health conditions.³⁰ The result of the Proposed Rule is likely to be the abrupt cessation of necessary care for transgender youth from families with low incomes. This population already faces compounding disparities, and the Proposed Rule will inevitably cause harm, because the population will be deprived of access to treatment to protect and advance their health.

The Proposed Rule mentions conversion therapy and posits throughout the text that psychotherapy is the only service that is credible and effective enough to help treat transgender youth. Research indicates that transgender youth who are supported and affirmed in their gender identity report improved mental health and feeling safer at school; however, transgender people subjected to banned treatments, such as “conversion therapy,” are at higher risk of suicide.³¹ Medical consensus considers conversion therapy, or therapy that attempts to change the gender and/or sexual orientation an individual identifies as, ineffective and dangerous.³² Therefore, conversion therapy is decidedly not recommended under existing standards of care. States across the U.S. and countries around the world have since banned the practice because it is dangerous and unhealthy. Patients who have undergone conversation therapy report increased suicidality, anxiety, and depression.³³

IV.           The Proposed Rule is inconsistent with Section 1557 of the ACA

The Proposed Rule is inconsistent with several provisions of federal law, including the ACA and the Medicaid Act. For instance, HHS asserts that the Proposed Rule does not constitute sex discrimination in violation of section 1557 of the ACA and HHS under U.S. v. Skrmetti, 605 U.S. 495 (2025). That Supreme Court decision did not address sex discrimination under section 1557, but rather under the Constitution’s Equal Protection clause. HHS should instead apply the reasoning in the Bostock decision, which found that, where sex is a “but for” cause of harm, there is sex discrimination.³⁴ In 2020, the U.S. Supreme Court considered whether statutory sex discrimination protections protected a person who had been fired from their job because they were transgender.³⁵ The Court held that it did, since discriminating against someone for being transgender “necessarily and intentionally discriminates against that individual in part because of sex.”³⁶ Because the Proposed Rule would prohibit Medicaid funding for the services at issue based on the sex of the person, and the person’s sex is the “but for” cause of the funding prohibition, the proposal violates section 1557.³⁷

V.             Conclusion

For the reasons stated above, we strongly oppose the Proposed Rule and urge HHS to withdraw the proposal in its entirety. Finalizing the proposal would put at risk the health of individuals with gender dysphoria by making it harder for them to access evidence-based, medically necessary, and potentially life-saving treatment.

We have included numerous citations to supporting research, including direct links to research. We direct HHS to each of the materials we have cited and made available through active links, and we request that the full text of each of the studies and articles cited, along with the full text of our comment, be considered part of the formal administrative record for purposes of the Administrative Procedure Act. If HHS is not planning to consider these materials part of the record as we have requested here, we ask that you notify us and provide an opportunity to submit copies of the studies and articles into the record.

1 See U.S. Dep’t Health & Hum. Servs., Treatment for Pediatric Gender Dysphoria: Review of Evidence & Best Practices (2025), https://opa.hhs.gov/sites/default/files/2025-11/gender-dysphoria-report.pdf.

2 See, e.g., G. Nic Rider et al., Scientific Integrity and Pediatric Gender Healthcare: Disputing the HHS Review, Sex. Res. & Soc. Pol’y (2025), https://link.springer.com/article/10.1007/s13178-025-01221-5; Nadia Dowshen et al., A Critical Scientific Appraisal of the Health and Human Services Report on Pediatric Gender Dysphoria, 77 J. Adol. Health 342 (2025), https://www.jahonline.org/article/S1054-139X(25)00246-0/fulltext.

3 See Am. Acad. of Pediatrics, News Release: AAP Statement on HHS Report Treatment for Pediatric Gender Dysphoria (May 1, 2025), https://www.aap.org/en/news-room/news-releases/aap/2025/aap-statement-on-hhs-report-treatment-for-pediatric-gender-dysphoria/; Am. Psych. Ass’n, APA Statement on Access to Treatment for Transgender, Gender Diverse, and Nonbinary People (May 1, 2025), https://updates.apaservices.org/statement-on-access-to-treatment-for-transgender-gender-diverse-and-nonbinary-people; Am. Acad. of Pediatrics, News Release, AMA and AAP Joint Statement on Evidence-Based Health Care (Nov. 19, 2025), https://www.aap.org/en/news-room/news-releases/aap/2025/ama-and-aap-joint-statement-on-evidence-based-health-care/; Am. Acad. of Child & Adolescent Psychiatry, AACAP Urges Science-Driven, Compassionate Care Following HHS Proposed Rules (Dec. 19, 2025), https://www.aacap.org/AACAP/zLatest_News/AACAP_Urges_Science-Driven_Care.aspx.  

4 See, e.g., Nadia Dowshen et al., A Critical Scientific Appraisal of the Health and Human Services Report on Pediatric Gender Dysphoria, 77 Journal of Adolescent Health 3 (2025), https://www.jahonline.org/article/S1054-139X(25)00246-0/fulltext; G. Nic Rider et al., Scientific Integrity and Pediatric Gender Healthcare: Disputing the HHS Review, Sex Res Soc Policy (2025), https://link.springer.com/article/10.1007/s13178-025-01221-5.

5 Am. Psych. Ass’n, Request for APA to be a reviewer for the HHS Report: “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” in Supplement to Treatment for Pediatric Gender Dysphoria: Review of Evidence & Best Practices: Peer Review and Replies 7 (U.S. Dep’t Health & Hum. Servs., ed. 2025), https://opa.hhs.gov/sites/default/files/2025-11/gender-dysphoria-report-supplement.pdf.

6 Richard J. Santen, Peer Review of Treatment for Pediatric Gender Dysphoria, in Supplement to Treatment for Pediatric Gender Dysphoria: Review of Evidence & Best Practices: Peer Review and Replies 24, 28. https://opa.hhs.gov/sites/default/files/2025-11/gender-dysphoria-report-supplement.pdf. Several of the report’s authors are noted critics of gender-affirming care, with little, if any, experience providing medical care to transgender youth. For example, author Evgenia Abbruzzese, is the founder of the so-called Society for Evidence-Based Gender Medicine (EBGM), which is listed by the Southern Poverty Law Center (SPLC) as an anti-LGBTQ hate group. See Southern Pov. L. Ctr., Anti-LGBTQ, https://www.splcenter.org/resources/extremist-files/anti-lgbtq (last visited Feb. 3, 2025).

7 What We Know Project, What Does the Scholarly Research Say about the Effect of Gender Transition on Transgender Well-Being. Cornell University (2018), https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people/.

8 Joanne LaFleur et al., Gender-Affirming Medical Treatments for Pediatric Patients with Gender Dysphoria, University of Utah College of Pharmacy L.S. Skaggs Pharmacy Institute (Aug. 6, 2024), https://www.researchgate.net/publication/400035576_Gender-affirming_medical_treatments_for_pediatric_patients_with_gender_dysphoria; See also Report to the Utah Legislature Health and Human Services Interim Committee, Transgender Medical Treatment and Procedures Amendments (S.B. 16, 2023) (May 2025), https://le.utah.gov/AgencyRP/reportingDetail.jsp?rid=636#.

9 Report to the Utah Legislature, supra note 8.

10 Indeed, off-label use of FDA-approved drugs is routine in the pediatric population. See, e.g., Divya Hoon et al., Trends in Off-Label Drug Use in Ambulatory Settings: 2006-2015, 144 Pediatrics e20190896 (2019), https://pmc.ncbi.nlm.nih.gov/articles/PMC7286122/;  H. Christine Allen et al., Off-Label Medication use in Children, More Common than We Think: A Systematic Review of the Literature, 111 J. Okla State Med. Ass’n 776 (2019), https://pmc.ncbi.nlm.nih.gov/articles/PMC6677268/.

11 Report to the Utah Legislature, supra note 8.

12 HHS, Medicaid Program; Prohibition on Federal Medicaid and Children's Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children, 90 Fed. Reg. 59444 (proposed Dec. 19, 2025), https://www.govinfo.gov/content/pkg/FR-2025-12-19/pdf/2025-23464.pdf.

13 See Marissa J Kilberg & Maria G Vogiatzi, Approach to the Patient: Central Precocious Puberty, 108 J. Clin. Endo. & Metab. 2115, 2119 (2023), https://academic.oup.com/jcem/article/108/8/2115/7076933.

14 Jonas F. Ludvigsson et al., A Systematic Review of Hormone Treatment for Children with Gender Dysphoria and Recommendations for Research, 112 Acta Pæd. 2279 (2023), https://pubmed.ncbi.nlm.nih.gov/37069492/.

15 See, e.g., D.M. Grijseels, Biological and Psychosocial Evidence in the Cass Review: A Critical Commentary, 27 Internat’l J. Trans. Health 278 (2026), https://www.tandfonline.com/doi/full/10.1080/26895269.2024.2362304; Julia K Moore et al., Cass Review Does Not Guide Care for Trans Young People, 223 Med. J. Aust. 331 (2025), https://onlinelibrary.wiley.com/doi/10.5694/mja2.70035; Chris Noone et al., Critically Appraising the Cass Report: Methodological Flaws and Unsupported Claims, 25 BMC Med. Res. Methodol. 128 (2025), https://link.springer.com/article/10.1186/s12874-025-02581-7; Meredithe McNamara et al., Yale L. Sch., An Evidence-Based Critique of “The Cass Review” on Gender-affirming Care for Adolescent Gender Dysphoria (2024), https://law.yale.edu/sites/default/files/documents/integrity-project_cass-response.pdf.

16 Moore et al., supra note 15, at 331.

17 HHS, Medicaid Program; Prohibition on Federal Medicaid and Children's Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children, 90 Fed. Reg. 59445 (proposed Dec. 19, 2025), https://www.govinfo.gov/content/pkg/FR-2025-12-19/pdf/2025-23464.pdf.

18 Id.

19 See, e.g., Germ. Ass’n Sci. Med. Soc’ies, Gender Incongruence and Gender Dysphoria in Childhood and Adolescence – Diagnosis and Treatment (English Version) (2025), https://register.awmf.org/assets/guidelines/028_D_G_f_Kinder-_und_Jugendpsychiatrie_und_-psychotherapie/028-014eng_S2k_Geschlechtsinkongruenz-Geschlechtsdysphorie-Kinder-Jugendliche_2025-06.pdf (guidelines for Austria, Germany, and Switzerland); François Brezin et al., Endocrine Management of Transgender Adolescents: Expert Consensus of the French Society of Pediatric Endocrinology and Diabetology Working Group, Arch. de Ped. (2024), https://www.sciencedirect.com/science/article/pii/S0929693X24001763#tbl0001 (guidelines for France).

20 Diana M. Tordoff, MPH et al, Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care (Feb. 25, 2022),  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/278942;Stephanie L. Budge et al, Gender Affirming Care Is Evidence Based for Transgender and Gender-Diverse Youth (Dec. 2024), https://www.jahonline.org/article/S1054-139X(24)00439-7/fulltext; USTS Transgender Survey 2022 (June 2025), https://transequality.org/sites/default/files/2025-06/USTS_2022Health%26WellbeingReport_WEB.pdf.

21 Report to the Utah Legislature, supra note 8.

22 See also Am. Acad. of Child & Adolescent Psychiatry, AACAP Statement Responding to Efforts to Ban Evidence-Based Care for Transgender and Gender Diverse Youth (Nov. 8, 2019) https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_ Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx; Am. Psychiatric Ass’n, Frontline Physicians Oppose Legislation That Interferes in or Criminalizes Patient Care (Apr. 2, 2021), https://www.psychiatry. org/newsroom/news-releases/frontline-physicians-oppose-legislation-that-interferes-in-or-criminalizes-patient-care; Wylie C. Hembree, et. al., Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, 102 J. Clin. Endo. & Metab. 3869–903 (2017), https://academic.oup.com/jcem/article/102/11/3869/4157558; Jason Rafferty, et. al., Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, 142 Pediatrics 1 (2018), https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for; Am. Med. Assoc., AMA Reinforces Opposition to Restrictions on Transgender Medical Care (June 15, 2021), https://www.ama-assn.org/press-center/ama-press-releases/ama-reinforces-opposition-restrictions-transgender-medical-care; Jack L. Turban et. al., Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation, 145(2) Pediatrics e20191725 (2020), https://pubmed.ncbi.nlm.nih.gov/31974216/. For a discussion on the effectiveness of hormone therapy, see Coleman, E. et al., Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7, 13 Int. J. Transgenderism 165–232 (Aug. 2012), https://www.tandfonline.com/doi/abs/10.1080/15532739.2011.700873.

23 Am. Psych. Assoc., APA Policy Statement on Affirming Evidence-Based Inclusive Care for Transgender, Gender Diverse, and Nonbinary Individuals, Addressing Misinformation, and the Role of Psychological Practice and Science (Feb. 2024), https://www.apa.org/about/policy/transgender-nonbinary-inclusive-care?_gl=1*2ug4re*_gcl_au*MjExNjAxODk3Ny4xNzcwMzk0OTIw*_ga*MTY0NTAxMTUzLjE3NzAzOTQ5MjA.*_ga_SZXLGDJGNB*czE3NzAzOTQ5MjAkbzEkZzEkdDE3NzAzOTcwMzAkajMyJGwwJGgw.

24 Am. Acad. of Pediatrics, AAP Reaffirms Gender-Affirming Care Policy, Authorizes Systematic Review of Evidence to Guide Update (Aug. 4, 2023), https://publications.aap.org/aapnews/news/25340/AAP-reaffirms-gender-affirming-care-policy. See also Jason Rafferty et al., Am. Acad. of Pediatrics, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents (Oct. 2018), https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for.

25 Am. Acad. of Child & Adolescent Psychiatry, Policy Statement on Access to Gender-Affirming Healthcare (June 2024), https://www.aacap.org/AACAP/Policy_Statements/2024/Access_Gender-Affirming_Healthcare.aspx.

26 Ilan H. Meyer, Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence, 129 Psych. Bull. 674 (2003), https://psycnet.apa.org/record/2003-99991-002; Katie A. McLaughlin et al., Childhood Adversity, Adult Stressful Life Events, and Risk of Past-Year Psychiatric Disorder: A Test of the Stress Sensitization Hypothesis in a Population-Based Sample of Adults, 40 Psych. Med. 1647 (2010), https://www.sciencedirect.com/science/article/abs/pii/S0010440X11000824; Jody L. Herman et al., The Williams Inst., Suicide Thoughts and Attempts Among Transgender Adults: Findings from the 2015 U.S. Transgender Survey (Sept. 2019), https://williamsinstitute.law.ucla.edu/publications/suicidality-transgender-adults/; Am. Psych. Assoc., Stress effects on the body (Mar. 8, 2023), https://www.apa.org/topics/stress/body.

27 Michelle M. Johns et al., Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students - 19 States and Large Urban School Districts, 2017, 68 Morbidity & Mortality Wkly Rep. 67 (2019), https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm (findings in a 2017 survey by transgender high school students revealed that over a third of respondents attempted suicide in the prior 12 months at 4 to 6 times the rate reported by their non-transgender peers). See also Brae Anne MacArthur et al., Suicidality and Nonsuicidal Self-Injury in Transgender and Gender Diverse Youth: A Systematic Review and Meta-Analysis, 180 JAMA Pediatrics 144 (2026), https://jamanetwork.com/journals/jamapediatrics/fullarticle/2842556?guestAccessKey=0ae30634-ea70-431b-a36e-9ad84a48cc25&utm_medium=email&utm_source=postup_jn&utm_campaign=article_alert-jamapediatrics&utm_content=etoc-tfl_&utm_term=020226 (estimating the risk of suicide at 2 to 3.5 times greater for transgender youth compared to non-transgender youth).

28 Id.

29 Juline A. Koken et al., Experiences of Familial Acceptance-Rejection Among Transwomen of Color 23 J. Fam. Psych. 853 (Dec. 2009), https://pubmed.ncbi.nlm.nih.gov/20001144/. USTS Transgender Survey 2022, supra note 20.

30 See, e.g., L. Zachary DuBoi et al., The Impact of Sociopolitical Events on Transgender People in the US, 2 Bull. Applied Trans. Stud. 1 (2023), https://bulletin.appliedtransstudies.org/article/2/1-2/1/.

31 Terryann C. Clark et al., The Health and Well-Being of Transgender High School Students: Results from the New Zealand Adolescent Health Survey (Youth ‘12), 55 J. Adolesc. Health 93 (Jan. 2014), https://pubmed.ncbi.nlm.nih.gov/24438852/; Jenifer K. Mcguire et al., School Climate for Transgender Youth: A Mixed Method Investigation of Student Experiences and School Responses, 39 J. Youth and Adolescence 1175 (Oct. 2010), https://pubmed.ncbi.nlm.nih.gov/20428933/; Stephen T. Russell et al., Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth, 63 J. Adolesc. Health 503 (Oct. 2018), https://pubmed.ncbi.nlm.nih.gov/29609917/; Lisa Simons et al., Parental Support and Mental Health Among Transgender Adolescents, 53 J. Adolesc. Health 791 (Dec. 2013), https://pubmed.ncbi.nlm.nih.gov/24012067/; Jack J. Turban et al., Psychological Attempts to Change a Person’s Gender Identity From Transgender to Cisgender: Estimated Prevalence Across US States, 2015, 109 Am. J. Pub. Health 1452 (Aug. 2019), https://pubmed.ncbi.nlm.nih.gov/31415210/; Erin C. Wilson et al., The Impact of Discrimination on the Mental Health of Trans*female Youth and the Protective Effect of Parental Support, 20 AIDS & Behavior 2203 (Oct. 2016), https://pmc.ncbi.nlm.nih.gov/articles/PMC5025345/.

32 See, e.g., Am. Med. Ass’n, Sexual Orientation and Gender Identity Change Efforts (So-Called “Conversion Therapy”) (2025), https://www.ama-assn.org/system/files/conversion-therapy-issue-brief.pdf; Am. Psych. Ass’n, Position Statement on Conversion Therapy and LGBTQ+ Patients (2024), https://www.psychiatry.org/getattachment/3d23f2f4-1497-4537-b4de-fe32fe8761bf/Position-Conversion-Therapy.pdf; Am. Acad. Child & Adol. Psych., Conversion Therapy (2018), https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx.

33 See, e.g., Nguyen K Tran et al., Conversion Practice Recall and Mental Health Symptoms in Sexual and Gender Minority Adults in the USA, 11 Lancet Psych. 879 (2024), https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00251-7; Anna Forsythe et al., Humanistic and Economic Burden of Conversion Therapy Among LGBTQ Youths in the United States, 176 JAMA Ped. 493 (2022), https://jamanetwork.com/journals/jamapediatrics/fullarticle/2789415; Christy Mallory et al., Williams Inst., Conversion Therapy and LGBT Youth (2019), https://williamsinstitute.law.ucla.edu/publications/conversion-therapy-and-lgbt-youth.

34 Bostock v. Clayton County, Georgia, 590 U.S. 644, 656 (2020).

35 Id.

36 Id. at 731.

37 See L.B. v. Premera Blue Cross, 795 F. Supp. 3d 1311, 1315 (W.D. Wash. 2025); see also Am. Ass'n of Physicians for Hum. Rts., Inc. v. Nat'l Institutes of Health, 795 F. Supp. 3d 678, 695 (D. Md. 2025) (violation of 1557 to terminate grants that “relate to LGBTQI+ health”).

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