Gender-Affirming Care

What Is Gender-Affirming Care

Gender-affirming care is medical and non-medical support that helps a transgender or gender-diverse person live according to their gender identity. It runs from a chosen name and pronouns through counseling, puberty blockers, hormones, and surgery for adults. Each stage has its own criteria, and most people never reach the last one.

This page is not medical advice. It summarizes current clinical standards, published research, state policy, and federal actions. Medical decisions belong with patients, families, and qualified clinicians. The care treats gender dysphoria, the diagnosis that names the distress this care is meant to relieve.

Can Your Family Still Get Care

What a family can still do depends on age, state, and who pays. If someone is in crisis, use the numbers in the box above first. Otherwise, open the situation closest to yours. This is general information as of September 24, 2026, not medical or legal advice.

What to do, by situation

My child is under 18 and our state bans this care

1. Check your state on the map below. In 24 states the ban is in force. In Kansas and Montana a court has blocked it.
2. The bans target puberty blockers, hormones, and surgery. Ask your child's therapist or pediatrician what they can still provide.
3. Several bans let patients already in treatment continue or taper off. Ask the prescriber what your state's law allows before a refill runs out.
4. Families who travel for care usually go to one of the 16 states or D.C. with a shield law. Talk to a lawyer first if your state's law penalizes parents.

The Movement Advancement Project links each state's law and notes which ones carry grandfather or taper clauses.

My child's care is paid for by Medicaid or CHIP

1. Federal payment for this care for minors ends October 13, 2026. For a child already on hormones, the state can keep billing federal Medicaid or CHIP for those medications for up to six months.
2. The rule stops federal money, not state money. Ask your state Medicaid agency whether it will keep paying with state funds.
3. Counseling stays covered. CMS says mental health services remain eligible for federal payment.
4. A coalition of 22 states and jurisdictions sued on September 2 to stop the rule. Watch for a court order before October 13.

The rule covers Medicaid patients under 18 and CHIP patients under 19 (CMS-2451-F).

I am an adult and want to keep or start care

1. The state bans on this page apply to minors. The federal Medicaid rule does too, and it says states may still cover adults.
2. If you buy insurance on HealthCare.gov or a state marketplace, plans can no longer count this care as an essential health benefit. Insurers may still cover it, so read the plan documents before you switch.
3. Some state Medicaid programs exclude surgery for adults. In March 2026 a federal appeals court upheld West Virginia's exclusion. Ask your state agency what it covers.
4. Some providers have stopped on their own, including Vanderbilt's adult surgery program. Southern Equality tracks closures.

Our clinic stopped seeing patients

1. Ask the clinic for complete medical records and a written referral before your last visit.
2. Ask whether patients already in treatment can continue or taper under your state's law.
3. Southern Equality's Trans in the South guide lists providers by state, along with help paying for care and telehealth options.

What Gender-Affirming Care Involves

Much of this care involves no medication and no surgery. It starts with social transition, which means a chosen name, different pronouns, a haircut, and clothes that match a person’s gender identity. None of that requires a doctor, and for many gender non-conforming kids it is where things stay.

The medical steps come later and arrive in a fixed order. Each one is harder to undo than the last, and each one is gated to an older patient. Those two facts move together, which is the part the political debate almost always leaves out.

The stages of care, from a chosen name to surgery

How permanent Fully reversible Partly permanent Permanent

1. Social transition Any age

   A chosen name, pronouns, hair, and clothing. Nothing is prescribed, and a child can change their mind at any point with no medical consequence.

2. Mental health care Any age

   Counseling for the patient and usually the family. Required before any medical step for a minor. Many patients take this step and no other.

   Provided by psychologists, clinical social workers, and psychiatry when another condition needs treatment

3. Puberty blockers Puberty onset

   These drugs pause puberty and buy time to decide. The FDA approved them in the 1990s for children who start puberty too early. Puberty resumes if a patient stops.

   Provided by endocrinologists, sometimes primary care

4. Gender-affirming hormone therapy Usually 16+

   Estrogen or testosterone, started at a low dose and raised slowly. Some effects fade if a patient stops. A deeper voice and facial hair do not.

   Provided by endocrinologists and trained primary care physicians

5. Voice therapy and hair removal Mostly adults

   Voice therapy trains pitch and resonance and changes nothing physically. Laser hair removal is permanent. Neither is covered by most state bans.

   Provided by speech-language pathologists and dermatology

6. Top surgery 16+ at some centers

   Chest reconstruction. Rare before 18 and never automatic: it takes lasting dysphoria, a mental health evaluation, and a parent's consent for anyone under 18.

   Provided by plastic surgery

7. Genital surgery Adults, almost always

   Also called bottom surgery. In national insurance data for 2019, 82 of 85 gender-affirming surgeries on minors were chest procedures, not genital ones. It requires a full assessment and informed consent.

   Provided by urology and plastic surgery

The stages of care, from a chosen name to surgery

Step	Age or stage required	How permanent
Social transition. A chosen name, pronouns, hair, and clothing. Nothing is prescribed, and a child can change their mind at any point with no medical consequence.	Any age	Fully reversible
Mental health care. Counseling for the patient and usually the family. Required before any medical step for a minor. Many patients take this step and no other.	Any age	Fully reversible
Puberty blockers. These drugs pause puberty and buy time to decide. The FDA approved them in the 1990s for children who start puberty too early. Puberty resumes if a patient stops.	Puberty onset	Fully reversible
Gender-affirming hormone therapy. Estrogen or testosterone, started at a low dose and raised slowly. Some effects fade if a patient stops. A deeper voice and facial hair do not.	Usually 16+	Partly permanent
Voice therapy and hair removal. Voice therapy trains pitch and resonance and changes nothing physically. Laser hair removal is permanent. Neither is covered by most state bans.	Mostly adults	Partly permanent
Top surgery. Chest reconstruction. Rare before 18 and never automatic: it takes lasting dysphoria, a mental health evaluation, and a parent's consent for anyone under 18.	16+ at some centers	Permanent
Genital surgery. Also called bottom surgery. In national insurance data for 2019, 82 of 85 gender-affirming surgeries on minors were chest procedures, not genital ones. It requires a full assessment and informed consent.	Adults, almost always	Permanent

Sources: WPATH Standards of Care, 8th Edition (2022); Endocrine Society Clinical Practice Guidelines (2017); Dai et al., JAMA Network Open (2024).

Nobody moves through every rung. A trans adult may take hormones for years and never want surgery. Another may want voice therapy and nothing else. The ladder describes what exists, not a path anyone is expected to finish.

Finding a provider is its own obstacle. There is no single specialty for this. A patient may see a primary care physician for hormones in one town and need an endocrinologist two hours away in the next, and the mental health services that the standards of care require are the hardest piece to find anywhere. Getting in the door is only half of it: 48% of trans adults report at least one bad experience with a provider because they were transgender, from being refused care outright to being treated roughly (2022 U.S. Trans Survey).

One clinical step almost never comes up in legislative debate. Before starting hormones, patients are counseled about fertility preservation, because testosterone and estrogen can reduce fertility. Teenagers and their parents are asked to consider banking eggs or sperm first. The conversation that lawmakers describe as reckless includes asking a 16-year-old whether they want the option of biological children at 30.

How Doctors Decide Who Gets Care

The process involves multiple providers, months of evaluation, and formal criteria at every stage. Accredited programs do not hand out hormones after one visit. The typical pathway moves through distinct steps: counseling and social support first, then assessment by trained providers, then puberty-stage evaluation if relevant, then parent permission and youth assent for minors, then reversible blockers when clinically appropriate, then hormones only after further evaluation, and surgery mostly limited to adults.

The WPATH Standards of Care, 8th Edition (2022) and the Endocrine Society Clinical Practice Guidelines (2017) set the clinical framework. Both require a comprehensive biopsychosocial assessment before any medical intervention.

The assessment can take months or longer, depending on the case. Before any medical step, providers evaluate family support, mental health, and whether the young person can understand and consent to what the treatment involves.

For minors, the process is family-centered. Parents provide permission. Adolescents provide assent. A mental health professional must confirm that the young person’s gender identity and dysphoria are long-lasting, intensified with puberty, and not better explained by another condition. Adults provide their own consent and need fewer gatekeeping steps, but the assessment is still required before hormones and mandatory before surgery.

Parents who have been through it describe something slower than the version debated in statehouses. Human Rights Watch interviewed 51 people across 19 states for a 2025 report on the bans. One father described what the first year looked like for his family.

Mental Health Outcomes and Regret Rates

The research compares people who received this care with people who wanted it and did not. The direction is consistent across studies: depression and suicidal thoughts fall in the group that got treated. The studies are observational, which is the center of the scientific dispute below. Most of them measure suicidal thoughts rather than suicide attempts or deaths, a gap HHS’s review pressed.

In a study of 104 youths at a Seattle clinic, those who started puberty blockers or hormones had 60% lower odds of moderate-to-severe depression and 73% lower odds of self-harm or suicidal thoughts over the first year (Tordoff et al., JAMA Network Open 2022). The same study found no change in anxiety.

The surgical regret rate needs its own context. A 2024 systematic review of 24 studies and 3,662 patients found pooled regret of 1.94%. It was higher after transfeminine surgery (4.0%) than transmasculine surgery (0.8%), and lower in the United States than elsewhere (Ren et al., Annals of Plastic Surgery).

Critics read the same literature differently. The Department of Health and Human Services’ review of the evidence, finalized in November 2025, concluded that the overall quality of evidence on psychological outcomes, regret, and long-term health “is very low.” It also said “there is no evidence that pediatric medical transition reduces the incidence of suicide.” England’s Cass Review reached a similar judgment in 2024. WPATH, which writes the clinical standards, answered the Cass Review that randomized trials would mean withholding treatment from teenagers in distress, so observational studies are the evidence that can ethically exist.

How Often People Detransition

Detransition means stopping or reversing a gender transition, and it is not the same as regret. Researchers separate social detransition, like returning to a birth name or pronouns, from medical detransition, like stopping hormones. Most people who do either still identify as transgender, and detransition is not evidence that the original care was a mistake.

How often it happens depends on how a study defines it. Clinic follow-up studies put medical detransition in the low single digits. The broadest count comes from the 2015 U.S. Transgender Survey, where 13.1% of respondents who had pursued any form of transition said they had detransitioned at some point, even briefly. A 2023 review in the Archives of Sexual Behavior found the true rate uncertain, because definitions and time windows vary so much.

When people do stop, the reason is usually outside pressure. In that survey, 82.5% of people who had detransitioned named at least one external reason. Pressure from family and social stigma were among the most common. Fewer than 1 in 6 (15.9%) named an internal reason, such as doubt about their gender identity (Turban et al., LGBT Health 2021).

The desistance debate sits beside this one and runs on the same problem. How researchers count children whose gender dysphoria resolves swings the reported rate from under 3% to over 90%, which the gender dysphoria explainer breaks down study by study.

The gap between how rare detransition is and how often it gets invoked is what the political fight exploits. In June 2026 the Texas Attorney General forced a hospital to open a detransition clinic and pay $10 million over care it had provided legally, turning a rare outcome into a weapon against the common one.

Common Claims vs the Evidence

Each of these claims about gender-affirming care circulates in political debate, much of it carried by the “gender ideology” label. Here is what the published record shows for each. Most are wrong, and one is partly right.

27 States Banned Care for Minors

Whether a transgender teenager can get care depends on where they live. Twenty-seven states have passed bans for minors. Twenty-four are in force, courts have blocked the bans in Kansas and Montana, and Arizona bans surgery only while its governor protects other care by executive order. Sixteen states and D.C. have shield laws that protect patients and providers from another state’s lawsuits and prosecutions, and Delaware does the same by executive order.

The map is still moving, and lately it has moved one way. Arkansas passed the first ban in 2021 and spent four years enjoined until the Eighth Circuit reversed in August 2025, applying Skrmetti. New Hampshire finished phasing its ban in on January 1, 2026, becoming the first New England state to prohibit the care.

Gender-Affirming Care for Minors

• Care ban in effect (24)
• Surgical ban only (1)
• Ban blocked by a court (2)
• Shield law protects access (17)
• Executive order protection (1)
• No ban, no shield law (6)

Sources: Movement Advancement Project, Bans on best practice medication for transgender youth; Movement Advancement Project, Transgender healthcare shield laws; Florida Statutes 456.52(5)(b), felony for practitioners; JAMA (2023), State Restrictions and Geographic Access to Gender-Affirming Care for Transgender Youth. Verified October 1, 2026.

Gender-Affirming Care for Minors

State	Status	Detail
Alabama	Care ban in effect	Felony to provide care. Up to 10 years.
Alaska	No ban, no shield law	No ban and no shield law.
Arizona	Surgical ban only	Surgical care banned for minors in 2022. A 2023 executive order by the governor protects the care that is still legal.
Arkansas	Care ban in effect	First ban (2021). Blocked until the Eighth Circuit reversed in August 2025.
California	Shield law protects access	Statutory shield. Protects providers and families.
Colorado	Shield law protects access	Statutory shield. Conversion therapy ban struck by SCOTUS March 2026.
Connecticut	Shield law protects access	Statutory shield law.
Delaware	Executive order protection	Executive Order 11 (June 20, 2025). Reversible by the next governor.
District of Columbia	Shield law protects access	Statutory shield law.
Florida	Care ban in effect	Full ban. Felony to provide care (Fla. Stat. 456.52). The median drive to the nearest clinic grew by 8.5 hours (JAMA, 2023).
Georgia	Care ban in effect	Surgery and hormone therapy banned.
Hawaii	Shield law protects access	Act 59, signed May 29, 2026, added gender-affirming care to the state shield law.
Idaho	Care ban in effect	Full ban. Felony offense.
Illinois	Shield law protects access	Statutory shield law.
Indiana	Care ban in effect	Full ban effective 2023.
Iowa	Care ban in effect	Full ban on hormones, blockers, surgery.
Kansas	Ban blocked by a court	Judge halted the ban in May 2026.
Kentucky	Care ban in effect	Full ban effective 2023.
Louisiana	Care ban in effect	Full ban effective 2024.
Maine	Shield law protects access	Statutory shield law (2024).
Maryland	Shield law protects access	Statutory shield law.
Massachusetts	Shield law protects access	Statutory shield law.
Michigan	No ban, no shield law	No ban and no shield law (MAP, September 2026).
Minnesota	Shield law protects access	Statutory shield law.
Mississippi	Care ban in effect	Full ban effective 2023.
Missouri	Care ban in effect	Full ban effective 2023.
Montana	Ban blocked by a court	Ban blocked May 2025 under state constitution.
Nebraska	Care ban in effect	Ban on care for under 19.
Nevada	No ban, no shield law	No ban and no shield law (MAP, September 2026).
New Hampshire	Care ban in effect	First New England state to ban. Surgery banned January 2025, blockers and hormones January 2026.
New Jersey	Shield law protects access	Statutory shield law.
New Mexico	Shield law protects access	Statutory shield law.
New York	Shield law protects access	Shield law strengthened December 2025.
North Carolina	Care ban in effect	Full ban effective 2023.
North Dakota	Care ban in effect	Full ban effective 2023.
Ohio	Care ban in effect	Full ban effective 2024.
Oklahoma	Care ban in effect	Full ban effective 2023.
Oregon	Shield law protects access	Statutory shield law.
Pennsylvania	No ban, no shield law	No ban and no shield law (MAP, September 2026).
Rhode Island	Shield law protects access	Statutory shield law (2024).
South Carolina	Care ban in effect	Full ban effective 2024.
South Dakota	Care ban in effect	Full ban effective 2023.
Tennessee	Care ban in effect	Full ban upheld by SCOTUS in Skrmetti (June 2025).
Texas	Care ban in effect	Full ban. AG Paxton investigated families.
Utah	Care ban in effect	Full ban effective 2023.
Vermont	Shield law protects access	Statutory shield law.
Virginia	No ban, no shield law	No ban and no shield law.
Washington	Shield law protects access	Statutory shield law.
West Virginia	Care ban in effect	Full ban on medical interventions for minors.
Wisconsin	No ban, no shield law	No ban and no shield law.
Wyoming	Care ban in effect	Full ban effective 2024.

Nearly half of trans youth ages 13-17 now live somewhere the care is banned or restricted (Williams Institute). The clustering is regional. In the South, 95% of transgender and non-binary youth live in states with restrictive laws. Six states treat providing the care as a felony.

The pressure no longer stops at 18, though it works through coverage and providers rather than bans. On March 10, 2026, the Fourth Circuit ruled that West Virginia’s Medicaid program may refuse to pay for gender-affirming surgery for adults. Applying Skrmetti, the panel wrote: “Just as Tennessee’s SB1 regulated treatments, not people, so too does West Virginia’s Exclusion” (Anderson v. Crouch). Some large providers have stopped adult care on their own. Vanderbilt University Medical Center ended adult gender-affirming surgery, and Catholic hospitals ended adult care after a directive from the U.S. Catholic bishops (Southern Equality).

What the Bans Permit

The bans are defended on one idea: children cannot consent to procedures that permanently change their bodies, so the state should step in. That argument is worth testing against the statutes themselves, because the exceptions are written into the same laws as the prohibitions.

A 2025 review examined all 30 ban statutes passed across 28 states between 2021 and 2024. It found that 29 of 30 carve out an exception for surgery on infants born with variations in sex characteristics, the children usually described as intersex (Mar et al., 2025). These operations are done to make a baby’s genitals look more typically male or female. They are rarely urgent, they are permanent, and the patient is too young to be asked.

Four of the statutes also write in an exception for infant circumcision. New Hampshire’s, for example, lets a provider remove healthy foreskin for “religious, cultural or health reasons.” Cosmetic breast and genital surgery on non-transgender teenagers sits outside the laws entirely, neither restricted nor excepted.

How the bans treat it

Prohibited · Cannot consent

No statute in the review prohibits a procedure on the ground that the child could not consent to it.

Prohibited · Asked for it

• Puberty blockers for a 13-year-old, with parental permission
• Hormone therapy for a 16-year-old, after a mental health evaluation
• Top surgery for a 17-year-old, with two providers and a parent agreeing

Permitted · Cannot consent

• "Normalizing" surgery on intersex infants (excepted in 29 of 30 statutes)
• Infant circumcision (excepted by name in 4 statutes)

Permitted · Asked for it

• Cosmetic breast and genital surgery on non-transgender minors (neither restricted nor excepted)

Did the patient ask for it?

Source: Mar et al., review of 30 U.S. statutes restricting care for transgender minors, 2021-2024.

Fourteen of the statutes go further and bar procedures that alter a “healthy,” “functional,” or “nondiseased” body part. None of the fourteen says who decides whether a body part qualifies. That judgment, which every one of these laws rests on, is left undefined in all of them.

The definitions do work of their own. Twenty-four of the thirty statutes define sex as a fixed binary set at birth, and sixteen make “nonambiguous” genitalia part of that definition. So the laws fix a child’s sex by the genitals they are born with, and then permit the surgery that makes ambiguous genitals unambiguous.

Who Is Behind the Bans

The bans did not emerge state by state from scratch. An Associated Press analysis of more than 130 bills in 40 states found many “identical or very similar to” model legislation from two groups: the Family Research Council, which endorsed Arkansas’s 2021 ban as a model, and Do No Harm, a physicians’ group founded in 2022 (AP analysis, via The Advocate). The wider campaign is covered in the anti-LGBTQ movement explainer and the Christian nationalism explainer.

1. The first state ban on this care for minors Arkansas's 2021 ban The Family Research Council endorsed it as a model for other states. ↓ Advocacy groups circulated model language
2. Model legislation from a physicians' group founded in 2022 Do No Harm model bill Montana's enacted ban "retained much" of its language, the AP found. ↓ Legislators introduced near-identical bills
3. Passed bans, many with similar preambles 27 state legislatures AP matched language in Arkansas, Iowa, Mississippi, and West Virginia. Six states made providing care a felony. ↓ Tennessee's ban reached the Supreme Court
4. Skrmetti (2025): upheld Tennessee's ban 6-3 U.S. Supreme Court Lower courts now apply it to other bans and to coverage rules.

Sources: Associated Press analysis of state bills (2023), reported by The Advocate; U.S. v. Skrmetti (2025); Movement Advancement Project.

The Supreme Court, in United States v. Skrmetti (2025), upheld Tennessee’s ban 6-3. It held that the law classifies by age and medical use, not by sex or transgender status, so it did not need heightened scrutiny. The Eighth Circuit applied the ruling to reinstate Arkansas’s ban in August 2025, and the Fourth Circuit applied it to adult Medicaid coverage in March 2026.

1. 1979 First standards of care Published by the group now called WPATH.
2. 1998 Dutch Protocol developed Puberty blockers introduced for adolescents with gender dysphoria.
3. 2021 Arkansas passes first ban Blocked in court until 2025. Endorsed as a model by the Family Research Council.
4. 2022 WPATH SOC8 published Updated clinical standards for adolescents and adults.
5. 2023 615 anti-trans bills filed 87 passed, across 49 states that considered them.
6. 2024 Cass Review published (UK) Found weak evidence for some youth treatments. Recommended a research model, not bans.
7. 2025 Supreme Court upholds Tennessee ban Skrmetti, 6-3.
8. 2026 Federal Medicaid rule finalized Ends federal payment for minors' care on October 13. 22 states and jurisdictions sue.

From clinical standards to state bans, 1979-2026: 1979: First standards of care (Published by the group now called WPATH.). 1998: Dutch Protocol developed (Puberty blockers introduced for adolescents with gender dysphoria.). 2021: Arkansas passes first ban (Blocked in court until 2025. Endorsed as a model by the Family Research Council.). 2022: WPATH SOC8 published (Updated clinical standards for adolescents and adults.). 2023: 615 anti-trans bills filed (87 passed, across 49 states that considered them.). 2024: Cass Review published (UK) (Found weak evidence for some youth treatments. Recommended a research model, not bans.). 2025: Supreme Court upholds Tennessee ban (Skrmetti, 6-3.). 2026: Federal Medicaid rule finalized (Ends federal payment for minors' care on October 13. 22 states and jurisdictions sue.).

1979: The Harry Benjamin International Gender Dysphoria Association, now the World Professional Association for Transgender Health, published the first clinical standards of care for transgender patients.

1998: Researchers in Amsterdam developed the Dutch Protocol, which introduced puberty blockers for adolescents with gender dysphoria. It became the clinical foundation used worldwide.

2021: Arkansas became the first state to ban this care for minors. Courts blocked the law until the Eighth Circuit reversed in August 2025, and the Family Research Council endorsed it as a model for other states.

2022: WPATH published the eighth edition of its Standards of Care, its current clinical guidance.

2023: Legislators filed 615 anti-trans bills, and 87 passed (Trans Legislation Tracker).

2024: England’s Cass Review found weak or low-certainty evidence for some youth treatments and recommended a research-based model of care, not bans.

2025: The Supreme Court ruled 6-3 in U.S. v. Skrmetti that Tennessee’s ban did not require heightened constitutional scrutiny.

2026: CMS finalized a rule ending federal Medicaid and CHIP payment for this care for minors, effective October 13. A coalition of 22 states and jurisdictions sued on September 2.

Where Federal Gender-Affirming Care Rules Stand

Twenty-seven states banned care through their own legislatures. The federal government is using an executive order, funding rules, and investigations to reach the states that did not. Two coverage rules are final, one broader rule is stalled, and two federal actions are blocked in court.

Where each federal action on gender-affirming care stands

As of September 24, 2026

• Medicaid and CHIP funding ban (CMS-2451-F) Agency action, final rule, minors only

  Takes effect October 13, 2026. Twenty-two states and jurisdictions sued in federal court in Massachusetts on September 2. (source)

• Hospital rule barring care for minors (CMS-3481-P) Proposal, stalled

  Drew more than 30,000 comments. The July 2026 regulatory agenda lists it as a long-term action with a December 2028 target, and HHS says it still intends to finalize it. (source)

• Marketplace coverage rule Agency action, final rule, plan year 2026 on

  Plans cannot count this care as an essential health benefit. Insurers may still cover it. Twenty-one states challenged the rule, and no court has blocked it. (source)

• Executive Order 14187 funding cutoff Blocked by a court, funding provisions

  A nationwide injunction in PFLAG v. Trump, and one covering Washington, Oregon, Minnesota, and Colorado, still block it. The Fourth Circuit denied a stay on April 16, 2026, refused full-court review of that denial on May 21, and the appeal continues. (source)

• HHS Secretary Kennedy's declaration on the standard of care Blocked by a court

  A federal judge in Oregon ruled for 19 states and D.C. in March 2026. NPR reported in July that the administration had not appealed. (source)

• Justice Department subpoenas for patient records In litigation

  Many have been blocked. On January 22, 2026, a Maryland judge quashed the demand for Children's National records. (source)

Source: Federal Register; NPR (July 13, 2026); Bloomberg Law; Manhattan Institute federal policy tracker (July 25, 2026); Vermont Daily Chronicle

The Medicaid rule takes effect October 13. It ends federal payment for “sex-rejecting procedures” for Medicaid patients under 18 and CHIP patients under 19 (Federal Register). States may still pay with their own money, and a child already on hormones can stay on them with federal funding for up to six months. The rule exempts treatment for “a medically verifiable disorder of sexual development,” the same carve-out for intersex children found in 29 of 30 state bans.

The hospital rule would go much further, barring any Medicare- or Medicaid-certified hospital from providing the care at all. It has not been finalized. Katie Keith, who directs Georgetown University’s Health Policy and the Law Initiative, told NPR that not withdrawing it lets CMS “keep the threat of doing so alive” and discourage providers even if the rule never takes effect. The American Medical Association and the Children’s Hospital Association both asked HHS to withdraw it (NPR, July 13, 2026).

The threat has already worked in states without bans. Dozens of hospitals closed their youth gender programs pre-emptively, including in California, Illinois, and New York, and Baystate Health in Massachusetts stopped youth care in February 2026 (NPR, April 17, 2026).

Provider landscape for trans patients

Period	Value
2020	Growing network of specialized clinics across the U.S.
2026	Dozens of youth programs closed in ban states and blue states alike
Change	Providers closing even where care is legal

Settlements have added a new tool. In June 2026 the Texas Attorney General required Texas Children’s Hospital to open a detransition clinic and pay $10 million over care it had provided legally, and NPR reported a similar settlement in Ohio. The administration’s Ryan White HIV/AIDS Program rules now bar providers from offering gender-affirming care as a condition of federal HIV funding, and Lambda Legal filed suit.

The Justice Department has sent administrative and criminal subpoenas to hospitals seeking full medical files for transgender youth. Courts have blocked many of them. Quashing the demand for Children’s National records, U.S. District Judge Julie R. Rubin wrote that it “appears to have no purpose other than to intimidate and harass” (Bloomberg Law). Seizing private medical records to police legal care is transphobia at an institutional scale.

Did Europe Ban Gender-Affirming Care?

The claim that “European countries banned gender-affirming care” is used to justify U.S. state bans. The health systems behind that claim restricted some treatments for minors. None of the five below banned them outright: each still provides them through research, exceptional cases or a specialized service.

The Cass Review (UK, 2024) found weak or low-certainty evidence for some youth interventions and recommended a more centralized, research-oriented model in England. It did not recommend criminal penalties or broad legislative bans. WPATH and USPATH formally objected to the review’s methodology, arguing it applied evidence standards designed for pharmaceutical trials to a field where randomized controlled trials are ethically impossible. You cannot give a control group of dysphoric teenagers a placebo and withhold treatment for years.

These countries restricted certain treatments for adolescents and routed the care that remains through specialized services or research. Most U.S. state bans prohibit puberty blockers, hormones and surgery for minors outright.

What Families and Providers Face in Ban States

In states where care was banned, some families relocated across state lines, and others began driving hundreds of miles each way for appointments in neighboring states.

Human Rights Watch documented families in ban states who watched their children’s mental health deteriorate after established treatment plans were interrupted. Providers who had managed a patient’s care for years were forced to stop overnight.

The fear runs ahead of the law. Several states have floated treating support for a child’s transition as child abuse, which puts social services in the picture and leaves parents weighing medical decisions against the risk of an investigation. One advocate described to Human Rights Watch what that does to families before any case is ever opened.

The mental health data shows what is at stake. The Trevor Project’s 2025 survey found that 44% of LGBTQ+ young people who wanted mental health care in the past year could not get it, and 40% of transgender and nonbinary young people seriously considered suicide. Among those using hormones, 87% said they worried about losing access (Trevor Project 2025). The 988 Suicide and Crisis Lifeline’s specialized line for LGBTQ+ youth lost its federal funding in July 2025.

The provider shortage extends beyond ban states. When hospitals in states without bans close their youth programs preemptively, families who thought they were protected discover they are not. Waiting lists at the remaining clinics grow and the drive gets longer. Families who can pay for travel reach another clinic, while families on Medicaid, who lose federal coverage for this care in October, have the fewest options.

Human Rights Watch took the title of its report from an 18-year-old trans woman, who was asked what she would say to the legislators writing these laws.

If someone is in crisis, call 911 for immediate danger, or call or text 988. The crisis box near the top of this page lists the Trevor Project and Trans Lifeline numbers.

Frequently Asked Questions

What are "sex-rejecting procedures"?

It is the federal government’s term for gender-affirming medical care, used in the 2026 Medicaid rule and the pending hospital rule. The Medicaid rule defines it as any drug or surgery that attempts to align a person’s body with an identity that differs from their sex, by suppressing development or altering the body. It exempts treatment for “a medically verifiable disorder of sexual development.” Medical groups call the same treatments gender-affirming care.

Do cisgender people get gender-affirming care?

Yes, and some of the same procedures are more common among them. In 2019 national insurance data, 146 of 151 breast reductions on minors were performed on cisgender boys, and no state ban restricts those. Puberty blockers were first approved for children who start puberty too early.

Do children get gender-affirming surgery?

Rarely. In 2019 national insurance data, 85 gender-affirming surgeries were performed on insured minors, 82 of them chest procedures, and none on children 12 or younger. Genital surgery is almost always limited to adults.

Are puberty blockers safe?

The Endocrine Society calls their effects reversible: puberty resumes when they stop. Doctors monitor bone density during treatment. HHS’s 2025 review and England’s Cass Review both rated the long-term evidence as weak, which is the core of the current dispute.

Will Medicaid still pay for my child's care after October 13, 2026?

Not with federal money. The rule ends federal Medicaid payment for patients under 18 and CHIP payment for patients under 19, with up to six months of continued hormone coverage for children already on them. States may keep paying with their own funds, and counseling stays covered. A coalition of 22 states and jurisdictions is suing to stop the rule.

Do the bans apply to transgender adults?

The state bans apply to minors. Adults face narrower limits: some state Medicaid programs exclude surgery, which a federal appeals court upheld for West Virginia in March 2026, and Marketplace plans can no longer count the care as an essential health benefit, though insurers may still cover it.

What are shield laws?

Laws in 16 states and D.C. that protect patients and providers from lawsuits and prosecutions brought by states where the care is banned. Delaware provides similar protection by executive order.

What is the Cass Review?

An independent review of youth gender care in England, published in 2024. It found weak or low-certainty evidence for some treatments and recommended a research-based model of care. It did not recommend criminal penalties or legislative bans. WPATH objected to its methods.

What happened in the Skrmetti case?

On June 18, 2025, the Supreme Court ruled 6-3 in U.S. v. Skrmetti that Tennessee’s ban on this care for minors did not require heightened constitutional scrutiny. Courts have since applied the ruling to reinstate Arkansas’s ban and to uphold West Virginia’s adult Medicaid exclusion.

What You Can Do

1. If your family relies on Medicaid or CHIP, call your state Medicaid agency before October 13. Ask whether it will keep paying for your child’s care with state funds and how a child already on hormones will be covered during the six-month transition.

2. Ask your state attorney general where your state stands on the lawsuit. A coalition of 22 states and jurisdictions sued on September 2 to stop the Medicaid rule. If your state is not part of it, ask why.

3. Support a shield law in your state. Thirty-two states have no shield law or policy. The Movement Advancement Project’s shield law map shows where yours stands, and your state legislators are the people to ask.

4. Know where to find care. Southern Equality’s Trans in the South guide lists providers and help paying for care. FOLX Health and Plume offer telehealth hormone care; check each service’s age limits and the states it serves.

5. Donate to groups defending access. The ACLU and Lambda Legal are litigating bans and federal rules. Southern Equality tracks provider closures in the South.

6. Ask your members of Congress to press HHS to withdraw its rules. Use the letter below.