On January 28, 2025, President Trump signed Executive Order 14187 (the “EO”), which directed the federal government to take steps to ensure that the federal government does not “sponsor, promote, assist, or support” the “‘transition’ of a child from one sex to another,” including the provision of gender-affirming care to individuals under the age of nineteen. Specific provisions of the EO directed, among other things, that: (1) all federal agencies rescind or amend all policies relying on guidance issued by the World Professional Association for Transgender Health; (2) federal agencies that provide research or education grants to hospitals and medical schools take “appropriate steps” to ensure that institutions receiving federal research or education grants end gender-affirming care to individuals under the age of nineteen; (3) the Secretary of the Department of Health and Human Services (“HHS”) take all appropriate regulatory and legal action to end gender-affirming care for individuals under the age of nineteen—such as through Medicare or Medicaid conditions of participation or conditions for coverage, clinical-abuse or inappropriate-use assessments relevant to State Medicaid programs; (4) the U.S. Attorney General to enforce an existing federal law against “genital mutilation” (18 U.S.C. § 116), and coordinate with state attorneys general to enforce state laws against gender-affirming care; and (5) the Director of the Office of Personnel Management include provisions in the Federal Employee Health Benefits and Postal Service Health Benefits programs call letter for the 2026 plan year specifying that eligible carriers exclude coverage for pediatric transgender surgeries or hormone treatments.
Federal Government Responses
The provisions of the EO related to research and education grants have been enjoined by two different federal courts (which are pending on appeal): (1) in the Western District Court of Washington, with the injunction only to apply to the states of Washington, Minnesota, Oregon, and Colorado, and (2) in the District Court of Maryland, with the injunction applying nationwide, though an emergency order to enforce the injunction was denied on March 28, 2025. However, federal agencies have already taken actions to implement the other provisions of the EO. On January 31, 2025, in accordance with the EO, the U.S. Office of Personnel Management (“OPM”) issued Carrier Letter Number 2025-01A, instructing insurance carriers for federal employees and postal workers (each carrier for federal employees, a “FEHB Carrier”, and each carrier for postal workers, a “PSHB Carrier”) to “‘exclude coverage for pediatric transgender surgeries or hormone treatments’ for the purpose of gender transition” for covered individuals under the age of nineteen for the plan year of 2026. Treatments excluded under this policy include “treatments prescribed for the purpose of delaying the onset or progression of normally timed puberty (including GnRH agonists),” “use of androgen blockers, estrogen, progesterone, and testosterone to align an individual’s physical appearance with an identity that differs from his or her sex,” and “surgical procedures used to align an individual’s physical appearance with an identity that differs from his or her sex”. The letter does allow coverage for surgeries or hormone treatments that are meant to facilitate gender transition for individuals above the age of nineteen, but it does not require such coverage. Carriers are required to comply with this letter for the plan year of 2026. OPM had previously issued Carrier Letter Number 2023-12 on May 23, 2023, preventing FEHB Carriers and PSHB Carriers and from excluding from coverage “services related to gender affirming care, such as hormone therapy, genital surgeries, breast surgeries, and facial gender affirming surgeries”, which Carrier Letter Number 2025-01A now supersedes.
Most recently, on April 11, 2025, the Centers for Medicare and Medicaid Services (“CMS”) issued a letter to State Medicaid Directors reminding states that the use of federal funds received by the State Medicaid programs as part of its federal financial participation for coverage of “procedures, treatments, or operations for the purpose of rendering an individual permanently incapable of reproducing” is prohibited for those procedures if they are performed on a person under the age of twenty-one (42 C.F.R. § 441.253(a)). The letter also reiterates the requirement that states maintain a drug utilization program that complies with Section 1927 of the Social Security Act (42 U.S.C. § 1396r-8) and implies that CMS will publish additional guidance on drug utilization program requirements regarding the prescription of drugs for gender-affirming care treatments, but does not currently implement any changes to the existing requirements. As support for its position, the letter cites studies on the prevalence of gender affirming treatment and to a review conducted in the United Kingdom that found poor quality of studies on gender dysphoria and a lack of reliable evidence to inform gender-based clinical decisions. CMS had previously issued a Quality & Safety Special Alert Memo on March 5, 2025, citing to the same studies as the April 11th letter on the denoted dangers and harmful effects of gender-affirming treatments.
HHS also recently agreed to drop its Biden-era appeal seeking to overturn a judicial order which prevented HHS from enforcing anti-discrimination provisions of the Affordable Care Act (the “ACA”) with respect to transgender individuals in Florida. Previously, in 2024, HHS had published a Final Rule with respect to Section 1557 of the ACA to clarify that such Section protected LGBTQ+ individuals by prohibiting entities receiving federal funding, including healthcare providers, from discriminating against transgender individuals. The State of Florida, several Florida government agencies, and the Catholic Medical Association filed suit and were granted an injunction which blocks the imposition of the anti-discrimination provisions in Florida. Under Biden, HHS appealed the injunction. However, at the request of HHS, the Court of Appeals for the Eleventh Circuit dismissed the appeal on April 3, 2025. This follows a similar dismissal in the Court of Appeals for the Fifth Circuit, where HHS dropped its appeal of a nationwide injunction in Tennessee and a Texas- and Montana-specific injunction in Texas. As a result, HHS may not enforce the anti-discrimination provisions in the ACA with respect to transgender individuals and accordingly, entities receiving federal funds, including certain Medicare payments, may face a low risk of enforcement by HHS as a result of denying care or coverage to transgender individuals.
Parallel State Government Actions
While the EO applies only to federal agencies, many states have also moved to reinstitute state-level prohibitions on gender-affirming care. On April 3, 2025, Ohio Attorney General Dave Yost appealed to the Supreme Court of Ohio to overturn a court order which blocks enforcement of a law preventing the use of hormone or puberty blocking treatments for transgender individuals under the age of eighteen, and also requested the Court prohibit any injunctive relief while the appeal is pending. The law had previously been passed over Governor Mike DeWine’s veto in January of 2024. If successful, doctors in Ohio would be prohibited from providing gender affirming hormone or puberty blocking treatments for transgender individuals under the age of eighteen.
In total since 2021 and as of March 19, 2025, twenty-seven states have passed bans on gender-affirming healthcare: Idaho, Utah, Montana, Wyoming, North Dakota, South Dakota, Nebraska, Kansas, Oklahoma, Texas, Iowa, Missouri, Arkansas, Louisiana, Kentucky, Tennessee, Mississippi, Indiana, West Virginia, South Carolina, Alabama, Ohio, North Carolina, Georgia, and Florida have banned gender-affirming care whether through medication and surgical procedures, while Arizona and New Hampshire have only banned gender affirming surgical care (though Governor Katie Hobbs of Arizona issued an executive order allowing transgender state employees to receive insurance coverage for gender-affirming healthcare services). A challenge to Tennessee’s ban on gender-affirming care is currently pending before the U.S. Supreme Court. The United States had originally filed briefs in support of the original plaintiffs in the case arguing that the Tennessee law violated the Equal Protection Clause of the Fourteenth Amendment, but in a letter dated February 7, 2025, the U.S. Department of Justice changed its position to state that it no longer holds the view that the Tennessee law violates the Fourteenth Amendment, but that the case should not be dismissed so that a ruling on the equal protection question will provide guidance to many cases currently pending in the lower courts.
Not all states, however, have enacted similar legislation. The District of Columbia and the following sixteen states have enacted a variety of protections for gender-affirming care, including “shield” laws to protect providers against enforcement actions initiated by other states that impose bans on gender-affirming care and mandatory insurance coverage for gender-affirming care procedures through application of state non-discrimination laws: Washington, Oregon, California, Arizona (though per the above executive order access is limited only to state employees), Colorado, New Mexico, Minnesota, Illinois, Maryland, New York, New Jersey, Connecticut, Vermont, Rhode Island, Massachusetts, and Maine. Additionally, several state attorneys general, including the state attorneys general of California and New York, have sent letters to individual healthcare providers warning them that withholding medical services from transgender individuals on the basis of their gender identity could violate state anti-discrimination laws.
Notably, on April 4, 2025, eleven states filed an amicus curiae brief in support of a lawsuit before the Court of Appeals for the Sixth Circuit seeking to overturn Michigan’s ban on conversion therapy for minors. Michigan state law prohibits treatment intended to change a person’s sexual orientation or gender identification “including but not limited to, efforts to change behavior or gender expression or to reduce or eliminate sexual or romantic attractions or feelings toward an individual of the same gender,” often referred to as conversion therapy. The plaintiffs in the initial lawsuit argued that the ban unconstitutionally prohibited therapists’ freedom of speech. A federal court judge for the Western District of Michigan found that the Michigan law does not intrude on a therapist’s First Amendment right and upheld the prohibition on conversion therapy. The plaintiffs then appealed to the Sixth Circuit. While this case does not directly involve gender-affirming care, all of the states which are party to the amicus curiae brief have implemented bans on gender-affirming care.
As the legal and political landscape continues to evolve, healthcare organizations and healthcare providers that offer gender-affirming care may face significant new legal, regulatory and financial risks, particularly where there is the potential for conflict between federal requirements and state laws. Even in the absence of direct conflict, there are significant differences between the EO’s stated objectives and state law restrictions on gender-affirming care, such as the specified age range to which the laws apply. The potential complexities and consequences resulting from such differences make it imperative that healthcare organizations and healthcare providers pay careful attention to developments relating to restrictions on gender-affirming care and consult legal counsel as necessary.