5 Principles and Practices to Sustain Gender-Affirming Care in Uncertain Times
HealthBegins September 16, 2025

Recent actions by the federal government have sowed confusion, chaos, and fear for patients and providers of gender-affirming health care. No federal laws have changed, but agency actions and public statements nonetheless threaten access to care for patients and funding for providers. Legal actions including Department of Justice investigations of doctors and clinics, subpoenas, demands for private patient data and threats of prosecution have heightened fear among providers that they could be personally targeted. Varying state laws, some prohibiting and some protecting gender-affirming care, complicate the picture.

Alarmed by these perceived threats and uncertain about what kind of enforcement to expect, several major U.S. hospitals abruptly stopped providing gender-affirming care, even for patients already in the midst of treatment. Many of these hospitals, facing protests, then reversed course and resumed care—some of them only to reverse again and halt care. Healthcare giant Kaiser Permanente took a modified course, pausing gender-affirming surgeries without shuttering clinics or halting other kinds of care.

The federal threats come as part of a broader political assault on transgender and nonbinary people and compound what was already a challenging environment for transgender patients seeking care.

Health care has a critical role to play to uphold standards of care, ensure access to essential services, advocate for evidence-based medicine, and protect patients and providers. (See healthcare institutions’ layers of influence visualized in HealthBegins’ Compass for Health Equity Transformation and Upstream Strategy Map.) As such, healthcare institutions can and should act to protect patients, staff, and access to evidence-based care, leveraging their roles as care providers, employers, community members, and policy influencers.

On gender-affirming care, healthcare leaders and practitioners can take essential steps to:

  1. Understand what the law is—and what it is not.
  2. Resist pre-compliance.
  3. Push back against junk science.
  4. Commit legal resources to protect healthcare providers.
  5. Build solidarity.

 

This article synthesizes expert guidance and offers references to explain how.

Note: HealthBegins does not provide legal services or advice. The following information is curated from reliable outside sources. We will continue to update this information as policies change and new or better resources come to our attention. We welcome your suggestions of additional resources and other policy topics for us to cover.

(Last updated: September 9, 2025)

1) Understand what the law is—and what it is not

The first step to responsible action is to cut through prevailing confusion and understand what recent federal actions actually do (and do not) mean. Most of the policy changes so far have come through executive orders. These are not laws.

In January, President Trump issued an executive order directing federal agencies to cease funding for medical institutions providing gender-affirming care to people under age 19. The Centers for Medicare & Medicaid Services (CMS) followed in March with a memo describing gender-affirming care as “dangerous chemical and surgical mutilation of children” and warning that it may take steps to prevent such care through its policies and provider requirements. In June, the U.S. Supreme Court ruled 6-3 that states could maintain bans on gender-affirming care for minors. Also in June, CMS finalized a rule that prohibits individual and small-group insurance plans from covering gender-affirming care as an Essential Health Benefit under the Affordable Care Act.

Advocates underscore that the executive order and CMS memo serve mainly as political messaging documents. They give broad directions to federal agencies, but it will take those agencies months or years to undergo the official processes required to implement those directions—and no one knows exactly how they will ultimately apply them. Importantly, no change is currently required of healthcare providers, and, while the Supreme Court has allowed the Trump administration to terminate NIH grants for political reasons, multiple court cases contesting the withholding of CMS funds are not yet resolved. Many observers expect the Supreme Court ultimately to allow key elements of these prohibitions to stand, but their legal status is not certain until that occurs.

At the state level, the Kaiser Family Foundation reports that 27 states have enacted laws or policies limiting or completely prohibiting youth access to gender-affirming care. Conversely, more than 15 states have enacted shield laws to protect gender-affirming care for minors and adults.

Resources:

  • Advocates for Trans Equality (AT4E) Trans Health Project
  • Williams Institute at UCLA School of Law, researching sexual orientation and gender identity law and policy. This Williams Institute analysis forecasts the executive order’s potential legal impact.
  • Kaiser Family Foundation policy tracker on youth access to gender-affirming care
  • Kaiser Family Foundation overview of President Trump’s executive actions affecting LGBTQ+ health
  • Joint letter by 15 state attorneys general affirming their commitment to protect gender-affirming care.

 

2) Resist pre-compliance

There’s a temptation amid fear to defensively cut contested budgets and programs before the law actually requires it. Yet pre-compliance carries its own risks. These include risks to patient care, reputation, mission, professional ethics—and, in some cases, the risk of breaking current law. Despite the recent executive actions, a set of federal and state laws, including Section 1557 of the federal Affordable Care Act, still state that employers, insurers, and medical groups must provide access to essential care. (Different federal administrations have differed on which kinds of care should count under that definition.) Healthcare institutions should set a goal to continue providing essential care to patients for as long as legally possible while executive actions are litigated.

An essential step in assessing any potential action is to consider forms of risk far more comprehensive than the short-term bottom line. A complete picture of value and performance, for example, includes patient satisfaction, staff retention, community standing, and commitment to the quadruple aim—factors counted in a broader Value on Investment assessment. 

While hewing to existing law, healthcare providers can take critical actions to strengthen care and access for LGBTQ+ communities. This can include steps to train staff in LGBTQ+ cultural competency, develop care protocols that align with World Professional Association for Transgender Health (WPATH) standards, partner with local organizations to provide community support, expand telemedicine options for patients who struggle to access local care, and provide insurance navigation and connections with organizations offering financial aid. 

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3) Push back against junk science

Forty years of research and practice provide evidence-based guidelines for gender dysphoria and gender-affirming care. Yet political polarization and hostility prevent a serious discussion about the evidence and its nuances. Some of the new federal and existing state restrictions conflict with established standards of care and are premised on unscientific assertions about biology that healthcare and public health leaders must debunk. Intentionally building this knowledge prepares you to have more clear and productive conversations inside and outside your institution.

The practice of gender-affirming care is guided by established standards of care from WPATH and the Endocrine Society. Gender-affirming care may include hormone treatments, puberty blockers (which are reversible), psychological counseling, and, in some cases, surgery. While opponents of gender-affirming care often cite surgery for transgender youth as a scourge, data shows that it is extremely rare. 

Thirty major medical organizations, including the American Medical Association (AMA), American Academy of Pediatrics (AAP), and American Psychological Association (APA), endorse gender-affirming care as medically necessary. In a letter to state governors, the AMA wrote, “Empirical evidence has demonstrated that trans and non-binary gender identities are normal variations of human identity and expression. … Every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people.”

However, another executive order in January, contradicting the AMA, redefined “sex” in federal programs as unchangeable and referring only to “male” or “female” biological traits observed at birth. This change does not directly implicate health care but blocks transgender people from maintaining their legal identity, which could affect their ability to secure a passport and receive public benefits such as food or housing assistance.

It’s essential for healthcare professionals to become familiar with the quality of evidence cited in political debates on gender-affirming care. For example, the Cass Review, often cited by opponents of gender-affirming care, has been criticized by other researchers as an unscientific and misleading analysis, resting on selective and inconsistent use of evidence, conducted by authors lacking in critical expertise. The U.S. Health and Human Services report published in May faces similar criticism. While some opponents of gender-affirming care for youth point to recent changes in the United Kingdom that limit access to such care, it is important to note that unlike actions by the U.S. administration, the U.K. policy does not ban care outright. The U.K. has also committed funding for research to build the evidence base for understanding this care rather than terminating funding for such research.

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4) Commit legal resources to protect healthcare providers

Healthcare systems should commit their (often substantial) legal resources to protect providers from investigations and other legal actions designed to intimidate them. Health systems should also recommit themselves to honor their obligations to protect patient confidentiality by challenging requests for sensitive patient information in court.

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5) Build solidarity

As organized opponents vilify and investigate medical providers practicing established standards of gender-affirming care, fellow providers and healthcare leaders find themselves isolated and threatened. History has recorded painful examples of physicians staying on the sidelines—or worse, actively collaborating. To do better, we must come together. 

Equipped with accurate information, you can support action within your organization. Fear and confusion can lead to misinformation and rushed decisions. Share reliable information and resources with colleagues. Encourage conversations rooted in evidence. Urge leaders to weigh a risk assessment broader than immediate financial impacts. Consider making space with peers or teams to process grief, fear, and anger and build solidarity—and caring for your own physical and spiritual health.

Beyond your organization, identify ways to leverage health care’s trusted position to advocate. As both medical professionals and large employers, healthcare institutions and leaders wield influence. Now is a critical time to use it to protect access to essential care. Health care can advocate for policies that sustain and improve access, protect patient well-being, and uphold evidence-based care, and they can educate policymakers on the medical necessity of gender-affirming care. 

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