The Trump administration sharpened its campaign against transgender people by targeting their health care Friday, issuing a new federal letter designed to help states eliminate Medicaid coverage for gender-affirming care for minors. It is the administration’s latest move in a relentless effort to legislate trans people out of public life.
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The letter, sent by the Centers for Medicare & Medicaid Services to state Medicaid directors across the country on Friday, warns that treatments like puberty blockers, hormone therapy, and certain surgeries for transgender youth may violate federal Medicaid rules. It cites explicitly a regulation barring sterilization procedures on people under 21 — a rule historically used for procedures like tubal ligations, not medical care for trans youth.
In the letter, CMS said its purpose was “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.”
CMS did not respond to The Advocate’s request for comment.
Adrian Shanker, who was a senior Health and Human Services official under President Joe Biden, told The Advocate the letter misuses Medicaid regulations to advance a political agenda targeting trans people.
“I don’t think this letter is using those regulations in good faith,” Shanker said. “This letter is using highly politicized language that is not grounded in the mountain of evidence that supports the underlying health and well-being of trans youth.”
“It frankly looks like a campaign document,” he added. “It looks like a document written by anti-trans activists rather than by public health professionals and health care leaders.”
A political weapon disguised as policy
“Dear State Medicaid Director” letters like this are not legally binding. They don’t carry the weight of formal rulemaking. But in the world of Medicaid — a federal-state partnership — these letters send a powerful signal about the federal government’s priorities.
Shanker warned that Republican-led states could now use the letter to cut off care where it is currently allowed.
“The significant fear here is that this ‘Dear State Medicaid Director’ letter will be utilized to preclude access to care even further in some states,” he said. “And the risk of that is actually very significant because we have incredible amounts of data that confirms the health impacts of denying access to care for trans youth.”
Medical experts reject the administration’s claims
The Trump administration claims gender-affirming care for minors lacks “reliable evidence” of long-term benefit — a claim rejected by every major U.S. medical organization, including the American Academy of Pediatrics, the Endocrine Society, and the American Medical Association.
Just last month, new medical guidelines from Germany, Austria, and Switzerland reaffirmed the importance of gender-affirming care, including puberty blockers, while rejecting the methodology of the U.K.’s Cass Review — a report frequently cited by U.S. conservatives seeking to ban trans care.
Matthew Rose, a senior public policy advocate at the Human Rights Campaign, called the CMS letter a deliberate attack on trans people under the guise of health policy.
“It’s deeply concerning that, at a time when thousands of federal health employees are being abruptly laid off without explanation and multiple public health crises break out across the country, CMS is focusing its time and taxpayer dollars spreading anti-science misinformation in order to interfere with health care decisions best made by families with their doctors,” Rose told The Advocate. “This approach is not only ignorant, it’s deliberately harmful to a community that depends on best-practice, evidence-based health care to live their most authentic lives.”
“A gross mischaracterization” — and a misuse of science
Kellan E. Baker, a transgender man and executive director of the Institute for Health Research and Policy at Whitman-Walker in Washington, D.C., told The Advocate the CMS letter marks an escalation of the administration’s attacks on trans health care.
“The purpose of this letter is to add fuel to the fire in states that are already seeking to ban care for transgender people, put politicians between parents and their kids, between doctors and their patients,” Baker said.
Baker called the administration’s use of sterilization regulations to target gender-affirming care “a gross mischaracterization” — and warned that the letter comes alongside another disturbing move from the Trump administration: directing the National Institutes of Health to study “regret” among people who have received gender-affirming care.
The administration’s directive has been widely condemned by health experts and LGBTQ+ advocates, who say it is part of a political effort to delegitimize trans identities.
Related: Trump orders NIH to study gender transition ‘regret.’ Here’s what we already know about it
“There is already a huge body of credible research about the experiences of transgender people — including regret rates, which are extraordinarily low,” Baker said. “Researchers working in this field are committed to understanding the full experience of transgender people — their health outcomes, their care trajectories, their needs. What this administration is doing is the opposite of that.”
Baker said the Trump administration is weaponizing federal research dollars to produce politically convenient results — not to advance knowledge or support public health. “It’s censorship masquerading as research,” Baker said. “It’s the perversion of the scientific enterprise.”
Studies show that regret following gender-affirming surgery is rare — affecting fewer than 1 percent of patients — far lower than for many other common medical procedures.
“These policies, these attacks, are hurting people,” Baker added. “They’re hurting real people.”
Advocates warn of broader bodily autonomy threat
LGBTQ+ advocates say the CMS letter is part of a much larger strategy — not only to restrict health care for trans people but to expand government control over individual medical decisions.
Olivia Hunt, director of federal policy at Advocates for Trans Equality, told The Advocate the Trump administration’s move disregards established medical standards and puts trans youth directly in harm’s way.
“Denying trans youth transition-related health care ignores the scientific and medical consensus, putting lives at risk,” Hunt said. “Transition-related health care is safe, effective, and lifesaving. Claims that trans youth are incapable of knowing themselves are false and stigmatizing.”
“CMS’s statement is part of a broader effort to control bodily autonomy, targeting not just trans people, but anyone seeking freedom over their own health care decisions,” she added.
States still have power
While the letter does not mandate changes to Medicaid coverage, Shanker said states opposed to the guidance should assert their authority.
“The way the Medicaid system is set up is that states and the federal government share certain responsibilities,” he said. “So states that disagree with this letter should remember their role in administering their state’s Medicaid program. I would encourage them to continue to ensure access to care for all people enrolled in Medicaid in their state, including trans youth and their families.”
