One week into his presidency, Donald Trump issued an executive order that aims to withdraw federal funds from any hospital that provides gender-affirming care to people under age 19. The order immediately drew criticism from clinicians, families, and legal advocates for transgender youth. On Tuesday, families of transgender youth filed a federal lawsuit asking for an order on hold.
“People need to recognize what this administration is willing to sacrifice in order to accomplish its ideological bent towards transgender people,” Meredithe McNamara, an assistant professor of pediatrics at Yale, said in an interview with STAT. “This administration is willing to turn off the lights in every children’s hospital, every neonatal ICU, and every pediatric emergency room, in every cancer ward, and pull funding so that hospitals will systematically deprive a very small group of patients health care.”
Two days after the order was issued, reports began to emerge of hospitals suspending care for young trans people in order to comply with the order. At least two hospitals in Colorado and Virginia suspended care. In the Northeast, NYU Langone canceled appointments for young people seeking puberty blockers and surgery. And Children’s Hospital Los Angeles, which has offered transgender youth services to hundreds of patients for years, said Tuesday that it was pausing the initiation of hormonal therapy for gender-affirming care patients under 19. Patients already receiving such therapy could continue to do so, CHLA said.
Gender-affirming care for youth — including puberty blockers, hormones, and in a small number of cases, surgery — is supported by major medical associations in the U.S. including the American Medical Association and American Academy of Pediatrics. A number of observational studies have produced evidence that receiving this care and having their identity affirmed improves the mental health of young trans people.
STAT spoke with McNamara, a specialist in adolescent medicine who provides gender-affirming care at a community health center in Connecticut, about the executive order, its effects on trans youth, and how institutions are responding.
The conversation has been edited for length and clarity.
Did it surprise you how quickly Trump acted on his campaign promises to defund gender-affirming care for youth? What was your reaction to the two gender-related orders?
No, it didn’t surprise me at all. When things actually happen and you have to deal with the consequences in real time, then you can actually start planning. But I think this is a tough thing to prepare for. Here we are in this place we’ve never been before where health care is being dictated through edicts written by a single office with these broad, sweeping implications. And we have no idea what to do about that.
Some hospitals have already started suspending gender-affirming care for people under 19 in the wake of the executive order. What have been the immediate consequences of that for young trans people?
Well, it is important to note that while there are a small handful of institutions that have responded [in this way] to the order, the vast majority are not stopping people’s health care at all. Even for NYU Langone, they were sharply reminded by [New York state Attorney General Letitia James] that there is a nondiscrimination clause in the state constitution that forbids them from withholding health care to people on the basis of sex, which is what cessation of gender-affirming medical services is. But I think for people who are regularly in care or were anticipating the initiation of care, to suddenly have that taken away from them is just really devastating. I think it amplifies a lot of very rational fears that people have right now. It forces families to quickly recalibrate their limited options, and that’s a very hard thing to do right now.
You mentioned the warning to New York hospitals that came from the state attorney general. In Virginia, hospitals were directed in the opposite direction by that state’s attorney general, which led to this care being suspended at multiple institutions. Do you think reactions to the order will vary by state, similar to how previous legislation on gender-affirming care for youth has broken down?
While I do think that political agendas are going to continue to carve up health care in this country, I think it’s important for people to actually understand what that means. It basically just constitutes the imposition of a narrow type of ideology on an entire population, which — we just don’t do that in health care. Our ethical principles preclude us from imposing our personal values on patients. We lose the ability to offer health care without discrimination or bias when political agendas encompass health care.
Medical associations like the AMA and AAP have not yet released statements on the executive order. Do you think it’s important for professional groups that have historically supported gender-affirming care to be vocal in this situation?
People in leadership roles are being very thoughtful about the most effective ways to maintain people’s access to health care. And it seems to me like people’s priorities in leadership positions are about minimizing or preventing interruptions in care, providing comfort to kids and families, and advocating for those who are vulnerable. I don’t know how much of that can actually be accomplished by broad, sweeping statements and press releases and that sort of thing.
There are a lot of people working tirelessly to prevent interruptions in care as much as possible. And those are people in those organizations, those are people in health care institutions, and those are people’s doctors. I think there is a lot of collaboration between all of those spaces right now. And I think the other thing that we have to remember is it has literally been a week since this happened. And we’ve never been here before. So I do think there’s a lot of value in just being careful and paying attention to what’s going on and gathering data. We cannot change the political vitriol of this administration or of the executive branch.
What do you make of the fact that the executive order on gender-affirming care is specifically directed at people under age 19, versus legal minors under the age of 18?
It’s hypocritical when you think about the different justifications being levied to excuse this type of interference in care — that you have to be an adult in order to decide. Well, we’re taking a large proportion of adults in this country and telling them that they cannot access this care because of their age. It doesn’t make sense. It doesn’t hold up. Now, I do think the reason why they chose the age of 19 is that it’s the age of legal adulthood in Alabama, if I’m not mistaken.
But what this actually means is you have college freshmen who are living independently, pursuing the next stage of their lives, entering adulthood, who are being told that they suddenly have to stop care. And I really do think that that should be deeply alarming for leaders in higher education throughout this country.
Do you think the administration will attempt to restrict or pull back care for older adults too at some point?
Yes, absolutely. We’ve seen restrictions on adult care be rolled out in states like Idaho and Florida. And there’s no reason to think that something similar won’t play out on the national stage.
The executive order regarding young people states that within 90 days, the secretary for the Department of Health and Human Services should publish a literature review on gender-affirming care. On Tuesday, Robert F. Kennedy Jr. cleared the Senate Finance Committee for that nomination, so it’s likely that will be him. What are your thoughts on that?
RFK Jr. was asked in a confirmation hearing if he said whether or not environmental pollutants are responsible for gender identity. He was then read back a quote of him saying exactly that, though he denied ever having said it. I anticipate that report will contain serious scientific errors, attempts to attribute gender identity to things that do not influence or cause it, and non-evidence-based recommendations for alternative treatments for people experiencing gender dysphoria. It will be a stunning example — and probably the first of its kind — of such an egregious document coming from an international health regulatory body, let alone an American one.
It’s going to be a really sad day when that gets released, and it’s going to make the work of people who describe and fight disinformation about health care that much more important.
As we saw late last week, federal websites and data are being stripped of “gender ideology.” What are the implications of losing this diverse gender information in public datasets?
First of all, I think it’s important for people to understand that the scientific community’s allegiance to the facts hasn’t changed just because some data has been scrubbed from a website. It’s still accessible. You can take stuff off online, but you can use the Wayback Machine in order to find it. And I think what that tells us is that the scientific community needs other ways to gather and study this data that don’t rely on an administration with an ideological bent against certain vulnerable minorities. So we just need to do things a little bit differently now.
I don’t want to send a message that, you know, we’re unable to study health disparities, you know, along the intersections of sex and gender and race and socioeconomic status, because we absolutely can still do that work. They have made it more difficult, but the work can and should and will continue.
I was very heartened to see how people rose to the occasion to pull as much data as possible, to rethink how we’re going to gather the state in the future. We don’t have unlimited energy out here in the academic research world. But people are tapping into new levels of commitment to eradicating health disparities, because our ability to do so is being carelessly threatened.
What action needs to be taken moving forward?
There’s a lot of capacity-building that institutions can do right now to respond to the moment. Regardless of whether or not institutions can maintain steady access to care, institutions are going to have to anticipate more mental health crises amongst LGBTQ youth. And they’re going to have to boost the behavioral health workforce in acute settings.
I also think that institutions are going to have to proactively try to protect patient privacy as much as possible and think about any weak points in their data protection or patient privacy systems, because we have to be able to assure patients that their information is confidential, otherwise they’re not going to come and see us.
And the other thing is that we are going to have to gather information about the harms of these executive orders in real time. As challenging as it is to speak up and out, I do think that parents of trans youth have such an important story to tell. I would encourage them to share their experiences to help educate institutional leaders and their elected representatives about what this care has meant for their children and what it would mean if it were to go away. I think we’re at a point now where we really need every family who’s willing and able to step up to the mic to talk about how terrible it is that suffering children would be denied medical care.