Comments From Richard Besser, MD, on the HHS Proposed Rule to Prohibit Gender-Affirming Care for Minors in Hospitals Participating in Medicare and Medicaid

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 Medicare and Medicaid Programs; Hospital Conditions of Participation: Prohibiting Sex-Rejecting Procedures for 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 hospitals that receive Medicare and Medicaid funding from providing gender-affirming care to individuals under 18. 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, including minors, and prohibiting hospitals from providing these services will harm individuals in need of care. Third, HHS underestimates the costs and administrative burden imposed by the proposal to ban provision of gender-affirming care in hospitals as a condition of participation.

I.               The Proposed Rule is Contrary to the Best Available Medical and Scientific Evidence on 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 Children’s Health Insurance Program (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.

The HHS Review also expresses concerns about the risks associated with gender-affirming care vis-à-vis the benefits of providing the services. These concerns, however, ignore the fact that, unlike for providers treating adults, providers treating pediatric patients routinely rely on their own clinical experience and the experience of trusted colleagues in making treatment decisions in the absence of specific, validated data, as could happen in some instances with gender-affirming care.¹² Every day, clinicians exercise their medical judgment, in accordance with state law, to make individualized recommendations based on the best evidence available combined with their clinical training, their experience treating prior patients, and conversations with colleagues. A treatment that works well for one patient may not work for another. Similarly, two patients with identical clinical profiles may make different informed choices about their care due to differences in their values, including how they and their families personally weigh the risks and potential benefits of each course of action. With the Proposed Rule, HHS seeks to override clinical decisionmaking and informed consent conversations with patients and families, even for patients who are not covered by federally funded healthcare programs.

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

In addition to the HHS Review, HHS relies on the experience of several European countries to justify the Proposed Rule. This analysis raises several concerns. 

First, some 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., study from the United Kingdom in support of the Proposed Rule. Researchers and experts have criticized the Cass et al., study for making contradictory claims about the evidence of psychological treatment and about the availability and further need to limit access to hormone therapy, and for disregarding studies finding that adolescents who requested but were unable to access gender-affirming medical treatment had poorer mental health compared with those who could access treatment.¹³

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. Sweden’s public healthcare system still allows hospitals and other providers to provide gender-affirming care to minors when medically necessary, even if the recommendation is that medical necessity should only be found in exceptional cases. In contrast, the Proposed Rule essentially leaves hospitals without an option given the financial constraints they would face without Medicare and Medicaid funding. As opposed to Sweden’s guidelines, the Proposed Rule effectively strips the authority to make final clinical decisions from medical providers.

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.¹⁴ 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 countries 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.¹⁵ 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.¹⁶

These findings are consistent with the overwhelming scientific and clinical evidence, which agrees that the services at issue are safe to treat gender dysphoria, and are effective treatments for that condition. This conclusion applies to all services at issue.¹⁷ 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.”¹⁸ 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.¹⁹ 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.”²⁰ 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.            Conditioning Medicare and Medicaid Funding to Hospitals on Refusal to Provide Gender-Affirming Care to Minors would Severely Harm Individuals with Gender Dysphoria

If HHS finalizes the Proposed Rule, it will significantly curtail access to medically necessary gender-affirming care for minors because hospitals and clinics within hospitals are one of the primary settings in which patients with gender dysphoria receive services. Even without the Proposed Rule, a significant number of hospitals have already stopped providing gender-affirming care for minors in response to other actions taken by the Administration that threaten the funding hospitals receive.²¹

Further curtailing of access to the services at issue will have severe consequences on the mental and physical health of minors with gender dysphoria. Debating the humanity of transgender people, especially children, adversely impacts their mental and physical health, as well as that of their families.²² 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.²³ Research consistently shows that transgender youth experience higher levels of violence or threats of violence than non-transgender students.²⁴ Transgender youth also experience rejection from their families and support systems because of their gender identity at higher rates than non-transgender youth.²⁵ 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.²⁶ Taking medically necessary care away from underserved populations who already face compounding disparities, like the transgender youth from families with low incomes who would be impacted by the Proposed Rule, will inevitably cause harm, because the population will be deprived of access to treatment to protect and advance their health.

IV.           HHS Underestimates the Costs and Administrative Burden Imposed by the Proposal to Ban Provision of Gender-Affirming Care in Hospitals as a Condition of Participation

HHS posits that the primary implementation costs for the approximately 4,800 hospitals subject to this rule will be in providing notices to patients that many transition-related services to treat gender dysphoria will no longer be available.²⁷ However, HHS does not estimate the number of actual providers and non-clinical staff working within those hospital systems who will be impacted. HHS also fails to adequately address significant costs and administrative burden of this rule, if implemented. Under the proposal, hospitals may still provide to individuals with other diagnoses services such as hormone treatment or puberty blockers, but hospitals cannot provide those same services to treat gender dysphoria. Hospitals and providers will need to develop, test, implement, and evaluate billing coding systems, operational procedures, manuals, policies, and trainings to distinguish between permissible and impermissible uses of these important and medically necessary services. HHS accounts for none of these costs and administrative burden to affected hospitals.

The burden that the Proposed Rule would impose on hospitals is compounded by the financial strains hospitals are facing due to cuts associated with several federal changes. For example, changes to Medicaid and Marketplace eligibility and enrollment introduced by the One Big Beautiful Bill Act (OBBBA), together with cuts to subsidies and other proposed Marketplace rules, will result in 16 million individuals losing insurance.²⁸ In addition, states are likely to begin cutting back on covered services and reimbursement rates in response to changes to the Medicaid provider tax formula.²⁹ As a result, hospitals will see a significant uptick in uncompensated care. Moreover, if OBBBA leads to an increase in the federal deficit, as the Congressional Budget Office projects, it would trigger further mandatory cuts to Medicare hospital payments.³⁰ The cuts will have a heightened effect on hospitals that serve rural and low-income communities, which were already facing tight operating margins before the changes.³¹ Additional cuts to reimbursement, through bans on provision on any services, such as gender-affirming care, will only add to the untenable position hospitals find themselves in, and will likely contribute to further hospital closures, making it more difficult for low-income and underserved individuals to access any type of hospital care.

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 essentially impossible for them to access evidence-based, medically necessary, and potentially life-saving treatment in hospital settings.

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 See Inst. on Med., The Ethical Conduct of Clinical Research Involving Children (Marilyn J. Field & Richard E. Berman, Eds., 2004) at 60–61, https://www.ncbi.nlm.nih.gov/books/NBK25557/.

13 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.

14 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).

15 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.

16 Report to the Utah Legislature, supra note 8.

17 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.

18 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.

19 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. 

20 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.

21 Theresa Geffney, STAT, Amid federal pressure, more hospitals stop gender-affirming care for minors (Feb. 5, 2026), https://www.statnews.com/2026/02/05/hospitals-stop-gender-care-minors-trump-administration-pressure/.   

22 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.

23 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).

24 Id.

25 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 15.

26 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/.

27 HHS, Medicare and Medicaid Programs; Hospital Condition of Participation:
Prohibiting Sex-Rejecting Procedures for Children, 90 Fed. Reg. 59473
(proposed Dec. 19, 2025), https://www.govinfo.gov/content/pkg/FR-2025-12-19/pdf/2025-23465.pdf.

28 Zachary Levinson et al., Kaiser Fam. Found., What are the Implications of the 2025 Budget Reconciliation Bill for Hospitals? (June 12, 2025), https://www.kff.org/medicaid/what-are-the-implications-of-the-2025-budget-reconciliation-bill-for-hospitals/.

29 Alice Burns et al., Kaiser Fam. Found., 5 Key Facts About Medicaid and Provider Taxes (Dec. 1, 2025), https://www.kff.org/medicaid/5-key-facts-about-medicaid-and-provider-taxes/.

30 Levinson et al., supra note 28.

31 Id.

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