As healthcare providers are no doubt aware, there has been a great deal of activity, both nationally and at the state-level, related to the Trump Administration’s actions aimed at prohibiting the provision of gender-affirming care to patients under the age of 19. This Update highlights activities occurring since Hancock’s last Healthcare Law Alert on this topic, issued on February 24, 2025.

Federal Court Challenges

Federal courts in Washington State and Maryland, on February 28, 2025 and March 4, 2025, respectively, issued preliminary injunctions in cases challenging the Trump Administration’s legal authority to proceed with various actions aimed at prohibiting the provision of gender-affirming care to patients under 19 years of age. The preliminary injunction in the Maryland litigation, PFLAG v. Trump, is applicable nationwide and enjoins the federal government from implementing Section 3(e) of Executive Order 14168 and Section 4 of Executive Order 14187, which otherwise would restrict, withhold, or terminate federal funding, including educational and research grants, to health care providers engaged in providing such care. The Trump Administration has appealed the injunction and the case has been partially stayed while that appeal is pending.

Federal Agency Activity

Even though the federal courts have enjoined the funding withholds as described above, a number of federal agencies have begun implementing those portions of the two Executive Orders not specifically stayed by the courts. The Office of Personnel Management (which manages several federal employee benefit programs), various agencies within the Department of Health and Human Services, and the Justice Department have all moved forward on these initiatives.

On January 31, 2025, the Office of Personnel Management issued Carrier Letter #2025-01A to those insurance and third-party payor organizations (“Carriers”) that will be administering the Federal Employee Health Benefit Plan and Postal Service Health Benefit Plan in 2026. The Carrier Letter advises Carriers (i) to ensure that all their plan materials refer to only two genders (male and female); and (ii) that they exclude coverage for transgender surgeries and hormone therapy for the purpose of gender transition for any individual under 19 years of age. Further, the Carrier Letter advises that Carriers, at their option, may choose not to cover these treatments for individuals over 19 years of age. In both cases, Carriers are advised to reduce premiums appropriately.

On March 5, 2024, the Centers for Medicare and Medicaid Services (CMS) issued a new Quality and Safety Special Alert Memo to hospital providers and other “Covered Entities” on “Protecting Children from Chemical and Surgical Mutilation”. The Memo (i) cautions providers regarding “dangerous chemical and surgical mutilation of children, including interventions causing sterilizations”; (ii) provides information on actions taken by other developed nations to prohibit or limit such practices; and (iii) indicates that CMS may begin taking steps in the future to “align policies, including CMS-regulated provider requirements and agreements, with the highest quality medical evidence in the treatment of the nation’s children”. The Memo notes that any such actions will follow the applicable substantive and procedural requirements.

On March 6, 2025, similar guidance was issued by the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration and the Office of the Assistant Secretary for Health.

On April 11, 2025, CMS issued a “Dear State Medicaid Director” Letter on “Puberty Blockers, cross-sex hormones and surgery related to gender dysphoria”. CMS indicates that its purpose in issuing the letter is two-fold, to (i) “ensure that state Medicaid agencies are aware of growing evidence regarding certain procedures offered to children”; and (ii) remind state agencies that that they must “ensure that Medicaid payments are consistent with quality of care and that covered services are provided in a manner consistent with the best interest of [Medicaid] recipients”.

On April 22, 2025, the United States Attorney General issued a Memorandum for Select Component Heads entitled, “Preventing the Mutilation of American Children”. Referencing Executive Order 14187, the Attorney General issued specific guidance in the following areas:

• Enforcement of laws outlawing female genital mutilation. The Attorney General refers medical practitioners, hospitals and clinics to 18 US § 116(a)(1), which imposes penalties up to 10 years in prison for individuals who, with respect to female genital mutilation on minors under the age of 18, knowingly perform, attempt to perform, and/or conspire to perform female genital mutilation, parents who consent and/or facilitate female genital mutilation, and individuals who transport such minors to receive female genital mutilation. Notably, the federal law has exceptions for such actions that are “necessary to the health of the person on whom it is performed” or is performed on an individual who has just given birth and the procedure is performed for medical purposes connected with labor and birth.

• Investigating and holding accountable medical providers and pharmaceutical companies that mislead the public about the long-term side effects of chemical and surgical mutilations. Specifically, the guidance directs the Civil Division’s Consumer Protection Branch to investigate any violation of the Food, Drug, and Cosmetic Act by manufacturers and distributors that make false claims about the on- or off-label use of puberty blockers, sex hormones, or any other drug used to facilitate a minor’s “gender transition”, including informal campaigns like those conducted by sales reps or under the guise of sponsored continuing medical education courses.

• Investigating possible false claims submitted to federal health care programs (Medicare, Medicaid, etc.) for any noncovered services related to radical gender experimentation. Specifically, the guidance directs the Civil Division’s Fraud Section to investigate possible violations of the Federal False Claims Act, actions such as (i) physicians prescribing puberty blockers to a child for an illegitimate reason (e.g., gender dysphoria) but reporting, for reimbursement purposes, that they were prescribed for a legitimate purpose (i.e., early onset puberty); and (ii) hospitals performing surgical procedures to remove or modify a child’s sex organs while billing Medicaid for an entirely different procedure. The guidance also notes that the Department is “eager” to work with qui tam whistleblowers who know of situations involving the described (or related) violations.

• Noting that the Civil Division has already directed Department of Justice employees not to rely on guidelines issued by the World Professional Association for Transgender Health (“WPATH”) (emphasizing that such directive applies to all Department employees), further directs such employees to withdraw all Department of Justice court filings that rely on WPATH’s guidelines, whether as a party, an amicus, or through the submission of a statement of interest. The guidance further directs the Civil Rights Division, in concert with the Civil Division, to identify and purge all Department policies, memoranda, and publications and court filings based on WPATH guidelines, asserting that WPATH has “flouted basic standards for clinical guidelines, silenced its own evidence review team to bury doubts about the science WPATH promotes, muzzled dissenting members, and worked with the [Biden] administration to push reckless policies-like doing away with age minimums for child surgeries.”

• Establishing the “Attorney General’s Coalition Against Child Mutilation”, through which the Department of Justice will partner with state attorneys general to identify leads, share intelligence, and build cases against hospitals and practitioners violating federal or state laws banning female genital mutilation and other, related practices, noting with favor Alabama’s Vulnerable Child Compassion and Protection Act 22, which makes it a felony for doctors to treat children with puberty blockers or hormones to affirm a gender identity inconsistent with biological sex.

• Directing the Department of Justice Department Office of Legislative Affairs to draft legislation to (i) amend 16 USC § 116 to enhance protection for children; and (ii) create a private right of action for children/parents of children whose healthy body parts have been damaged by medical professionals through chemical and surgical mutilation, including long statutes of limitations and retroactive liability.

On April 28, 2025, the White House issued a Fact Sheet summarizing the initial steps that had been taken to implement Executive Order 14187. Shortly thereafter, on May 1, 2025, the Department of Health and Human Services issued a lengthy report, entitled, “Treatment for Pediatric Gender Dysphoria – Review of Evidence and Best Practice”. The report notes that, “it does not issue legislative or policy recommendations. Rather, it seeks to provide the most accurate and current information available regarding the evidence base for the treatment of gender dysphoria in this population, the state of the relevant medical field in the United States, and the ethical considerations associated with the treatments offered.” Further the report indicates that it is, “intended for policymakers, clinicians, therapists, medical organizations and, importantly, patients and their families” by summarizing, and critically evaluating, “existing literature on best practices for promoting the health and well-being of children and adolescents with distress related to their sex or to social expectations associated with their sex.” Since its issuance, the veracity and reliability of the report has been debated in the press and by academic and advocacy organizations by both those supporting and those critical of the report.

State Court Action

There is also action at the State level. As of March 19, 2025, 27 states ban gender-affirming healthcare while the District of Columbia and 16 states have enacted legal protections for gender-affirming care. On April 29, 2025, the Ohio Supreme Court allowed Ohio’s ban on gender-affirming care for minors to remain in place while the appeal of a lower court’s determination that the ban was unconstitutional proceeds through the appeal process. In Alabama, advocates and state and federal authorities have asked the court to close a legal challenge to that state’s ban on certain gender-affirming care after three years of litigation. In Missouri, advocates, as well as the Missouri Attorney General, are awaiting a final court decision on whether a state law prohibiting gender-affirming care to minors is constitutional. That state’s Supreme Court preliminarily enjoined the enforcement of this law pending conclusion of the litigation.

Closer to home, as noted in the previous Alert, the New York State Attorney General has been vocal that New York providers who/that stop providing, or otherwise limit, minors’ access to gender-affirming care could be violating New York laws.