DOJ and HHS Signal Future Actions to Block Access to Treatment for Trans Youth

Editors: Patti Boozang and Amanda Eisenberg
Authors: Bryant Torres, Julian Polaris and Aliya Bean

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tl;dr

• Federal agencies are continuing to take action to implement President Trump's executive order (EO) aimed at blocking access to care for transgender individuals under the age of 19, including a recent DOJ memo and HHS report released in the span of 10 days. 

• Neither action changes existing legal requirements with respect to Medicaid coverage or payment for or provider delivery of gender affirming care for transgender youth, nor do they compel any action by state Medicaid programs or providers. 

• These actions have created hesitancy and confusion among families and providers; states can mitigate these impacts by clearly communicating their coverage and payment policies for these services to providers and families. 

The 80 Million Impact

Federal agencies are continuing to take action to implement President Trump’s January 28 EO aimed at blocking access to care for transgender individuals under the age of 19. U.S. Attorney General Pam Bondi, on April 22, circulated an internal memo calling on the Department of Justice (DOJ) to enforce existing federal laws — including regarding off-label promotion of drugs like hormones and puberty blockers — and advance new legislation restricting gender-affirming care for youth. On May 1, 2025, the Department of Health and Human Services (HHS) released a report presenting the Trump administration’s conclusions on the clinical evidence and ethics of health care for transgender youth. 

It appears the federal government is building an administrative record to cite when taking future action to shut down coverage of gender-affirming care for young people or penalize the providers who offer it. The American Academy of Pediatrics (AAP) has already weighed in on the HHS report, stating that it “misrepresents the current medical consensus and fails to reflect the realities of pediatric care” and that “[p]atients, their families, and their physicians — not politicians or government officials — should be the ones to make decisions together about what care is best for them based on evidence-based, age-appropriate care.” 

These steps follow prior federal actions, including HHS signaling funding risks for providers who serve transgender youth and suggesting limits on Medicaid coverage for youth gender-affirming care. The common themes are that none of these actions change existing legal requirements regarding treatment for transgender youth and that all appear to be crafted to promote hesitancy and fear among impacted patients, families, providers and payors, including state Medicaid programs. 

DOJ memo calls for investigations, enforcement and future legislation  

The DOJ memo directs its “employees to enforce rigorous protections and hold accountable those who prey on vulnerable children and their parents.” While it does not directly change current legal requirements for providers who serve transgender youth, it suggests that bottom surgery for minors assigned female at birth (AFAB) — a procedure rarely, if ever, offered to those under 18 — may violate a federal law prohibiting female genital mutilation (FGM). The provider-focused sections of the memo signal DOJ’s commitment to enforcing existing legal requirements (e.g., accurate billing and coding for services, complying with state gender-affirming care bans). For the manufacturers and distributors of drugs used in gender-affirming care, the memo signals DOJ’s intent to investigate potentially unlawful off-label use promotion.  

• Billing and coding for providers. DOJ commits to vigilant enforcement of proper billing and coding for gender-affirming care services, still, this doesn’t change any legal standards in these areas. Providers that bill or code inaccurately for any service (not just gender-affirming care) that result in greater coverage or reimbursement under federal health care programs are at risk of liability under the False Claims Act. False claims suits can be filed by the federal government or by private whistleblowers. The memo provides examples of improper billing and coding, such as “physicians prescribing puberty blockers to a child for an illegitimate reason (e.g., gender dysphoria) but reporting a legitimate purpose (i.e., early onset puberty) to CMS” and “hospitals performing surgical procedures to remove or modify a child's sex organs while billing Medicaid for an entirely different procedure.” To minimize risk under the False Claims Act, providers should, as they do today, continue to comply with each payor’s guidelines on coverage and billing for gender-affirming care.  

• Compliance with state laws banning gender-affirming care. Through the newly established “AG’s Coalition Against Child Mutilation,” the DOJ intends to coordinate with states that have laws banning care for transgender youth to investigate and prosecute violations of these state laws.¹ 

• Future risks for providers: private right of action. The memo previews the administration’s plan to encourage Congress to pass legislation that creates a private right of action allowing recipients of gender-affirming care youth services (or their parents) to sue providers — similar to the private rights of action some states have created for abortion recipients and their family members. Any such legislation would likely not be retroactive and would apply only to services furnished after the law’s effective date. 

• Concerns for drug manufacturers and distributors. DOJ asserts that, “even if otherwise truthful, the promotion of off-label uses of hormones — including through informal campaigns like those conducted by sales reps or under the guise of sponsored continuing medical education courses — run afoul of the FDA's prohibitions on misbranding and mislabeling.” The memo does not express an intent to investigate providers, community organizations or other third parties that may communicate with the public about gender-affirming drugs. 

• Ambiguity for providers that offer bottom surgery for youth assigned female at birth. The memo of the “federal criminal prohibition on FGM” for minors — a prohibition that could conceivably apply only to bottom surgery for minors AFAB (which few, if any, providers offer today). Notably, the memo does not discuss the FGM law’s exception for procedures that are “necessary to the health” of a patient and performed by licensed practitioners, and so does not provide meaningful guidance to providers about the circumstances (if any) under which a provider can be liable for FGM by performing bottom surgery for minors AFAB in accordance with state law. Although DOJ can reinterpret existing federal laws, DOJ must provide clear notice to the public of any change in criminal liability. This memo arguably fails to provide such clarity.  

HHS report presents the Administration’s conclusions on the clinical evidence and ethics of health care for transgender youth  

The HHS Office of Population Affairs (OPA) report is directed toward “policymakers, clinicians, therapists, medical organizations and, importantly, patients and their families,” and shares the administration’s view that the risks of gender-affirming medications² and surgeries for youth outweigh the benefits. Like previous HHS action, the new report does not compel any immediate action by state Medicaid programs or providers of care. The executive summary confirms that the report “is not a clinical practice guideline, and it does not issue legislative or policy recommendations.”  

HHS has not identified the individuals who contributed to the report. The agency notes that contributors “include medical doctors, medical ethicists, and a methodologist” who “represent a wide range of political viewpoints.” However, HHS states that their names are “not initially being made public in order to help maintain the integrity of this process.” HHS also notes that gender-affirming care for adults is a separate topic and is not addressed in the report.  

Physicians including from the AAP and other physician groups have issued statements opposing the report, which at over 400 pages, provides the Trump administration’s perspective on the lack of clinical consensus related to the evidence on care for trans youth, medical ethics considerations for providers and “psychotherapy,” as the sole recommended intervention in place of gender-affirming care services for youth who identify as transgender.³ 

The Bottom Line

To be clear (if we haven’t sufficiently hit our 80 Million readers over the head with this point): neither the DOJ memo nor the HHS report directly change any current legal requirements for state Medicaid programs that cover gender-affirming care services or providers seeking to treat transgender youth. But they do create hesitancy and confusion among families and providers, and state Medicaid agencies should consider communicating formally and informally what the program covers in terms of gender affirming care for youth, and, for providers, the specific codes that should be used to bill for these services. 

These recent actions do underscore the administration’s desire for providers to cease treatment for transgender youth and compile a body of evidence in favor of the administration’s position against such treatment. They also preview how agencies may seek to penalize states and providers that continue providing care to transgender youth, which could include a new Condition of Participation that would prohibit Medicare and Medicaid providers from offering gender-affirming care to youth. Given ongoing litigation on President Trump’s EOs underlying these actions — including court orders blocking the administration from implementing certain aspects of the EO — we anticipate that further action by federal agencies to restrict access to care for transgender youth will be subject to continued legal challenges.  

[1] As of May 2025, 27 states have a ban on care for transgender youth. 25 states have bans on best practice medication and surgical care for transgender youth, though ban may not be in effect. Two additional states (New Hampshire and Arizona) have a ban on surgical care for transgender youth. See Movement Advance Project for additional information on state laws.  

[2] Puberty blockers and gender-affirming hormones are rarely prescribed to transgender adolescents. A recent study of private insurance claims over the last five years showed that less than 0.1% of adolescents received prescriptions for puberty blockers or hormone therapy. Another study on privately insured claims found that there were no gender-affirming surgeries conducted on individuals aged 12 years and younger, and procedures on individuals 12-17 were rare. 

[3] In particular, the report favorably discusses therapy aimed at discouraging medical transition. 

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