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Hundreds of thousands of transgender people could lose access to medical treatment or be forced to detransition under a little-known Republican effort to defund trans healthcare for both adults and children.
Since Republicans took control of the House of Representatives last January, GOP lawmakers on Capitol Hill have quietly added a wave of amendments to "must-pass" government funding bills that would ban federal money from being used for gender transition procedures such as hormone therapy and sex reassignment surgery.
These riders vary widely in their scope and effect. Some target government health programs such as Medicare and Medicaid. Others would revoke insurance coverage for transgender government employees. Still others would bar federal funding for any institution that "promotes transgenderism".
Taken together, though, they would drastically curtail trans people’s access to medical care that advocates routinely describe as critical to their flourishing – much as the 1977 Hyde Amendment restricted abortion access in the wake of Roe v Wade.
"I remember a time when my own medical transition was the only thing going right in my life, and to have it taken away from me would have been existential at least," says Gillian Branstetter, a communications strategist for the American Civil Liberties Union (ACLU)’s LGBTQ and HIV Project. "This healthcare saved my life and the lives of trans people I know and love."
To be clear, GOP lawmakers aren’t seeking to limit these procedures for everyone. The proposed restrictions would only apply when they are done as part of a medical transition, and not when they are given to cisgender (or non-trans) people to treat other conditions.
And while such riders currently have little hope of passing a Democratic Senate and presidency, they are a preview of what could happen if the GOP wins back power this November — and Republican lawmakers tell The Independent that is exactly the plan.
"Certainly, I’d be hopeful that they would go through [if Trump wins] – that we would stop taxpayers’ dollars being used for things that taxpayers in Montana don’t support," said Montana Republican Matt Rosendale, who authored a House amendment banning US military personnel and their families from receiving transition care through their Pentagon health insurance.
That change will affect a lot of service members. Trans people are two to five times more likely to serve in the US military than cis people, and the military is widely believed to be the country’s biggest employer of trans people.
Asked by The Independent whether he was concerned about interrupting people’s healthcare, Rosendale said: "I don’t think that taxpayers’ dollars should be used for surgeries that change the physical appearance."
Indeed, last week the Republican National Committee officially made cutting off taxpayer funding for all "sex change surgeries" part of its 2024 policy platform.
Other legislators were more diffident. "Yeah? So?" said Maryland Republican Andy Harris, a medical doctor on the House appropriations committee who backed several anti-trans amendments, when buttonholed by The Independent on the Capitol steps on Thursday before Congress left for recess.
Pressed on why he supported those amendments, he said: "Because there should be no special rights."
Meanwhile, West Virginia senator Joe Manchin, who recently left the Democratic Party to become an independent, bizarrely claimed to be unaware that he had voted for a similar pair of amendments – only for his office to reverse course within 24 hours and say he did support them.
Trans people and their allies, however, do not feel so blasé.
"Losing this crucial access to gender affirming care would be devastating to our community," says Ash Orr of Advocates for Transgender Equality (A4TE), a Washington DC non-profit.
"It is not hyperbole that passing federal legislation to ban transgender healthcare, just like with abortions, would lead to unnecessary deaths."
How routine funding bills have become a battleground
There is a broad consensus among medical researchers that gender transition is effective, and frequently necessary, in treating gender dysphoria. What exactly that involves is different from person to person.
The most common treatment is hormone replacement therapy (HRT), which masculinizes or feminizes the body over a span of months and years. Many trans people also find that it brings about a holistic improvement in their wellbeing and self-esteem. Though relatively cheap, it must be taken continuously throughout one’s life, and stopping it will reverse some (though not all) of its effects.
Some trans people also get surgeries to alleviate their dysphoria, such as genital reconstruction, breast removal and augmentation, or orchiectomy (ie, testicle removal). These are more permanent, but far more expensive, and often have a long recovery period.
Such procedures aren’t exclusive to trans people. Cis women take HRT to mitigate side effects of menopause, or even acne; children receive puberty blockers to prevent premature sexual development; and intersex people undergo genital reconstructive surgery, frequently without their consent in early childhood.
Those instances, however, are not what GOP lawmakers are taking aim at. Their objection is to taxpayer funding of gender transition specifically, and the centerpiece of their efforts is a highly bureaucratic but incredibly consequential process known as appropriations.
Every year, Congress must pass 12 spending bills to keep the government open by "appropriating" money from the US treasury. Each bill funds a different cluster of federal agencies, such as the State Department or the Department of Health and Human Services (HHS).
Traditionally this process has been relatively non-partisan. However, the must-pass nature of these bills creates an opportunity for members to force the spotlight onto their pet issues, proposing amendments that would get little traction in a standalone vote. Republicans have made gender-affirming care one of those issues.
Last year seven out of 12 appropriations bills were amended in the House to restrict trans healthcare, according to a report by the Human Rights Campaign (HRC) – part of a raft of anti-LGBT+ additions ranging from bans on flying Pride flags above federal properties and blocking the enforcement of non-discrimination laws.
This year similar riders were stealthily attached to bills appropriating funds for the Department of Homeland Security, the State Department, the Department of Defence (DoD), and HHS.
That last bill is particularly important because it funds Medicare, which provides health insurance to around 65m older and disabled people, and Medicaid, which does the same for roughly 85m on low incomes.
In June, House Republicans amended this year’s iteration of the annual National Defence Authorization Act (NDAA) to revoke coverage for trans healthcare under the Pentagon’s sprawling Tricare health insurance program, which serves around 9.6m current and former service members and dependents. The Senate version of the NDAA was also amended to ban the DoD from paying for trans surgeries.
All this legislation dovetails an ongoing nationwide campaign to ban transition healthcare for under-18s and impose criminal sanctions on doctors who perform it, at both the local and federal level.
"These anti-trans riders don’t just target healthcare for trans youth, but adults of any age," says Orr. "[That] indicates what we already knew: the battle over our bodily autonomy does not come from a concern for the safety of adolescents, but from opposition to self-determination and bodily autonomy."
'Losing this healthcare is an existential threat'
How would such laws actually impact trans life in America?
According to the Williams Institute, an LGBT+ research non-profit based in Los Angeles, there were around 164,000 trans adults enrolled in Medicaid plans that covered transition care as of 2022.
The 2015 US US Transgender Survey (USTS) also found that around 7.8 per cent of trans adults had health insurance through Medicare, Tricare, another military scheme, or the US Department of Veterans’ Affairs, as well as up to 0.9 per cent insured by the Indian Health Service. With an estimated US transgender population of 1.6m, that would amount to roughly another 125,000 to 141,000 people.
Not every person counted in these numbers would necessarily seek medical transition. On the other hand, they do not include the unknown number of trans people who bought federally-subsidized coverage through a health insurance marketplace – which could also be affected by some riders, according to A4TE – or who work for the federal government and get insurance from their employer.
Many individual hospitals and health systems across the country also receive federal aid. While in theory they could ring-fence this money to keep it away from transition care, some might simply stop offering such procedures – just as several major hospitals in red states have already done for minors.
For some affected trans people, this would mean a scramble to find some other way of getting medical care, potentially at considerable personal or financial cost. For others it would mean treatments being delayed or blocked entirely.
Those denied surgery might have to live with bodily features that make them miserable, while those compelled to stop HRT would undergo an involuntary medical transition – or even, if they no longer had the ability to produce their own hormones, a forced menopause.
"Gender-affirming care serves as the foundation for the lives that trans people lead," Branstetter says. "It gives us the freedom to be ourselves and to build our own futures...
"If you deny that to them, or you pull it away, that leaves them with very little hope and very little ability to continue to move through the world. And that’s one reason why we have this notoriously high suicide rate."
Dr Jack Turban, director of the University of California San Francisco’s gender psychiatry program, and the author of Free to Be: Understanding Kids & Gender Identity, likewise says that denying transition care would cause "a substantial adverse public mental health impact."
That damage, Branstetter argues, would compound the deep discrimination that trans people already face in housing, employment, and other areas of life. As with the Hyde Amendment, it would also fall disproportionately on trans people of color and those in poverty, who are more likely to be on Medicaid and have fewer resources to pursue alternatives.
These bills aren’t happening in isolation. In addition to the GOP’s broad-spectrum war against trans rights and healthcare, the Heritage Foundation – an influential hyperconservative think tank – has proposed sweeping efforts to push trans people out of public life as part of its ambitious ‘Project 2025’ manifesto.
Hence, if next year’s session of Congress opens with Republicans in control of all three branches of government, both Branstetter and Turban fear that withholding taxpayer dollars will only be the beginning.
"Anti-trans politicians have been working to identify more and more creative ways to restrict access to care for transgender patients," says Turban.
"I don’t think there’s any reason to think that will stop, and this next election will have a dramatic impact on transgender Americans and their ability to access gender-affirming medical care."
