Submitted via Federal eRulemaking Portal: http:// www.regulations.gov
February 17, 2026
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-2451-P
Re: [CMS-2451-P] RIN 0938-AV73 Medicaid Program; Prohibition on Federal Medicaid Funding for Sex-Rejecting Procedures Furnished to Children and Youth
Dear Dr. Oz and Secretary Kennedy,
Human Rights Watch submits this comment in opposition to the proposed rule issued by the US Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS), RIN 0938-AV73; CMS-2451-P, Medicaid Program; Prohibition on Federal Medicaid Funding for Sex-Rejecting Procedures Furnished to Children and Youth, published on December 19, 2025.
Human Rights Watch is a nonprofit, nongovernmental human rights organization that investigates and reports on human rights abuses in approximately 90 countries. For four decades, we have documented violations and pressed governments and institutions to comply with their obligations under international law. We have published numerous reports on discrimination and abuse faced by transgender people in the United States, including the severe harms that result when transgender youth are denied medically necessary care.
In June 2025, Human Rights Watch published a 98-page report, “They’re Ruining People’s Lives”: Bans on Gender-Affirming Care for Transgender Youth in the US, documenting the severe harms transgender youth and their families experience when laws restrict access to evidence-based, medically necessary care.[1] Between 2023 and 2025, Human Rights Watch conducted 51 interviews with transgender youth, parents, and healthcare providers in the US. Our findings show that severe restrictions on gender-affirming care can destabilize young people’s mental and physical health and force families into impossible choices—paying unaffordable costs out of pocket or going without care altogether. The proposed rule would replicate and expand these harms nationwide with a blanket denial of coverage of gender-affirming care for young people, while also requiring states to impose parallel restrictions. This rule would thus harm people everywhere in the United States, even in states that have thus far taken steps to ensure that young transgender people will continue to be able to obtain evidence-based, quality, affordable care regardless of family income.
The proposed rule would require State Medicaid plans to “provide that the Medicaid agency will not make payment under the plan for” gender-affirming care for individuals under age 18 and would prohibit the use of federal Medicaid dollars for such care.[2] The proposed rule would also require that separate State Children’s Health Insurance Program (CHIP) plans “provide that the CHIP agency will not make payment under the plan” for gender-affirming care for individuals under age 19 and would prohibit the use of federal CHIP dollars for such care.[3]
Title XIX of the Social Security Act authorizes federal grants to States for Medicaid programs to provide medical assistance to individuals with limited income and resources,[4] and Title XXI authorizes federal grants to States to provide child health assistance to targeted low-income young people under age 19 through a separate CHIP, a Medicaid expansion program, or a combination of the two. Separate CHIPs are programs under which a State receives federal funding from its Title XXI allotment to provide child health assistance through coverage that meets the requirements of section 2103 of the Act and 42 C.F.R. § 457.[5] Medicaid and CHIP are administered primarily by States, subject to federal oversight and approval. If States comply with federal Medicaid and CHIP statutes and regulations, including through implementation of their federally approved State plans, the federal government matches States’ expenditures with federal funds. Each State Medicaid program and CHIP must be described and administered in accordance with a federally approved State plan.
Medicaid and CHIP are foundational components of the US health care system, covering nearly half of all children in the US and enabling millions of young people to access essential health services.[6] The proposed rule would bar federal funding for State programs that cover evidence-based medical care for transgender young people when provided for the purpose of affirming a person’s gender identity. In doing so, the proposed rule would deny low-income young people access to medically necessary care, exacerbate health inequities, and undermine basic standards of nondiscriminatory health coverage.
The proposed rule would jeopardize transgender young people's right to health under international human rights law. The International Covenant on Economic, Social and Cultural Rights (ICESCR), which the United States has signed but not ratified, recognizes in article 12 the right to the highest attainable standard of physical and mental health.[7] While the Convention is not binding on the United States, the ICESCR, along with the interpretive guidance that has grown up around it, is a useful and authoritative guide to how policymakers should work to realize the human right to health that all people enjoy. Under the ICESCR framework, governments are required to ensure the right to health is enjoyed without discrimination based on race, sex, religion, or “other status,” which the Committee on Economic, Social and Cultural Rights interprets to prohibit discrimination on the basis of sexual orientation and gender identity.[8]
Under the ICESCR, the right to health explicitly includes accessibility of healthcare goods and services without discrimination. General Comment 14, which interprets the right to health under the ICESCR, states that accessibility is defined by non-discrimination, physical accessibility, economic accessibility, and information accessibility.[9] It states that “health facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups.”[10] The proposed rule would dramatically reduce available care options for low-income transgender young people seeking gender-affirming care, undermining their right to the highest attainable standard of health.
The proposed rule would also violate transgender young people’s right to freedom from discrimination under international law. Article 26 of the International Covenant on Civil and Political Rights (ICCPR) guarantees equal protection of the law without discrimination.[11] The UN Human Rights Committee has interpreted this to prohibit discrimination based on gender identity, among other grounds.[12] Restrictions on gender-affirming care, such as the proposed rule barring Medicaid and CHIP funding for this care, constitute discrimination by denying transgender individuals access to medically necessary treatment for “gender dysphoria,” a condition which is based on one’s gender identity.
For the reasons set out below, Human Rights Watch urges CMS and HHS to withdraw the proposed rule in its entirety.
I. The Proposed Rule Disrupts and Undermines Best Practice Medical Care
The proposed rule would restrict access to gender-affirming care for Medicaid and CHIP beneficiaries in a way that would deny access to the careful, clinically guided provision of gender-affirming care in healthcare settings. The proposed rule ignores the substantial body of evidence demonstrating that such care can improve health outcomes for many transgender young people.[13] In practice, the proposed rule would deny low-income transgender young people access to medically necessary, evidence-based care and expose them to serious, foreseeable harms.
Under prevailing norms of good practice, gender-affirming care for transgender youth is provided through a slow, individualized, and iterative clinical process, consistent with clinical practice guidelines developed by the Endocrine Society[14] and the World Professional Association for Transgender Health (WPATH).[15] These guidelines are supported by major medical associations including the American Medical Association,[16] the American Academy of Pediatrics, the American Psychological Association,[17] and the American Academy of Child and Adolescent Psychiatry.[18]
These standards recommend that gender-affirming care be provided through a multidisciplinary healthcare team, which may include therapists, pediatricians, pediatric endocrinologists, and other specialists as needed. Standards make clear that parents and guardians should nearly always be involved.[19] In appropriate cases, social workers, affirming faith leaders, and other supportive professionals may also help families navigate care as part of a broader support system.[20]
Gender-affirming care often begins with social transition, a non-medical process that may include adopting a new name, using different pronouns, changing clothing styles, and altering hairstyles. Social transition can allow transgender youth to explore their gender identity and expression without medical intervention. For many young people, social transition alone is insufficient, such that other interventions are helpful or even necessary to alleviate significant mental distress.
Consistent with prevailing clinical standards, young people seeking medical care typically undergo individualized assessment, including mental health screening. For adolescents who continue to experience persistent dysphoria and seek medical support, treatment may include puberty-delaying medication and hormone therapy.
Puberty-delaying medications and menstrual suppressants may be offered early in puberty—in consultation with the young person, their parents or guardians, and medical providers—to pause unwanted pubertal changes. The effects of puberty-delaying medications and menstrual suppressants are considered reversible.[21] These medications are often used to give young people time to continue exploring their gender identity before potentially pursuing other care later in adolescence or adulthood. Studies indicate that access to puberty-delaying medications can improve mental health outcomes for young people who desire this treatment.[22]
Hormone therapy is generally considered safe when appropriately prescribed and monitored.[23] Depending on the duration of use, some effects may be partially reversible.[24] As with other medical treatment, informed consent includes discussion of potential risks, benefits, and side effects, including possible impacts on fertility. Major medical associations have emphasized the importance of discussing infertility risk and fertility preservation options prior to initiation of hormone therapy.[25]
Many of the medications used as part of gender-affirming care have long been used in pediatric care for non-transgender patients. For example, puberty-delaying medications have been prescribed for decades, including since the FDA approved them in 1993 for treatment of precocious puberty, a condition in which children enter puberty unusually early.[26]
In the United States, gender-affirming surgeries are exceedingly rare among transgender youth. Available evidence indicates that such procedures are far more common among non-transgender youth, including procedures used to align bodies with sex assigned at birth. A study published in the Journal of the American Medical Association (JAMA), analyzing US medical data from 2019, found that of approximately 150 cases of youth under age 18 receiving gender-affirming surgery, 97 percent were chest reduction surgeries for non-transgender male youth with gynecomastia (a condition causing enlargement of mammary tissue in males).[27] The study further found that among adolescents ages 15 to 17, the rate of undergoing gender-affirming surgery with a transgender-related diagnosis was 2.1 per 100,000.[28]
Most youth who receive gender-affirming care continue this care into adulthood, with a continuation rate of approximately 98 percent.[29] This high continuation rate aligns with evidence of the care’s importance: studies have consistently found that gender-affirming care is associated with improved mental health outcomes, including lower rates of depression and suicidality.[30]
Human Rights Watch has interviewed dozens of families about the impact of receiving this care at a critical time in adolescence, and many of them detailed the significant degree of thought and the painstaking processes in place that ensured their child was receiving comprehensive, quality care.
Sarah, the mother of a 17-year-old trans girl described how she secured care for her daughter, Mylie, years before her state banned this care. After nine months of counseling and evaluation by a pediatric psychologist, Mylie began seeing a pediatric endocrinologist in her hometown in 2019, when she was 12 years old.[31]
Over the course of four years, Mylie’s physician adjusted her treatment to match her development, allowing her to mature alongside other girls in her grade. Both Sarah and Mylie described how puberty-delaying medication and hormone therapy reduced Mylie’s dysphoria by preventing unwanted pubertal changes and allowing her to develop in ways consistent with her identity. Mylie said this care enabled her to live more openly and fully.
Before her social and medical transition, Mylie experienced bullying related to her appearance and faced distress when using the bathroom. Feeling unsafe in either the boys’ or girls’ restroom, she restricted her water intake throughout the school day, a behavior that may have contributed to the development of kidney stones. After her transition, Mylie reported feeling safer and more confident using the girls’ bathroom with support from her school, and no longer experienced kidney issues.
As Sarah recalled:
“For her to come out as a young child and have that kind of atmosphere where she'd be supported, she was given the opportunity to have the blockers so her body did not go further into a transition into a body that she does not identify with… her voice never dropped… and [she was] able to go to the bathroom… All those things immediately reduced the anxiety.”[32]
Mylie added:
“It was much more enjoyable to be in school. I didn't have to worry about my gender identity or what I presented as. I just had to worry about school at that time.”[33]
The proposed rule rests on a distorted description of gender-affirming care that is contradicted both by leading medical authorities and by the experiences of patients and families. As noted above, under clearly-established standards of good practice, gender-affirming care is a gradual and tailored clinical process grounded in holistic assessment, monitoring, and informed consent, and for many young people it is essential to prevent distress and safeguard health.
The proposed rule would undermine the comprehensive, multidisciplinary nature of gender-affirming care and make it much harder for young people to access high-quality care in line with prevailing standards . Research suggests that many young transgender people and their families have gone to tremendous lengths to obtain gender-affirming care in the face of state restrictions and federal threats, largely because of the profoundly positive effects of that care.[34] Withholding federal funding for that care makes it more––not less––likely that families will have to forego certain aspects of best-practice care, experience long waiting times and disruptions in care, or have fewer choices of providers and possible treatment options that best meet their particular and individualized needs. To the extent that CMS and HHS are invested in improving treatment outcomes and ensuring that young people experience effective, quality care, greater funding and support for high-quality treatment, not the withdrawal of support for families obtaining this care, is essential.
II. The Proposed Rule Threatens Young Transgender People’s Physical and Mental Health and Well-Being
The proposed rule claims to advance statutory requirements for Medicaid State plans under sections 1902(a)(19) and 1902(a)(30)(A) of the Social Security Act. Section 1902(a)(19) requires safeguards to ensure that care and services are provided “in a manner consistent with the best interests of the recipients,”[35] and section 1902(a)(30)(A) requires that payments be consistent with principles of efficiency, economy, and quality of care.[36] The proposed rule also invokes CHIP requirements under section 2101(a) of the Act, which reflects Congress’s intent that CHIP funds help States provide health care services to uninsured, low-income young people in an effective and efficient manner and in coordination with other sources of coverage.[37]
The proposed rule would undermine these stated aims. By prohibiting federal Medicaid and CHIP funding for gender-affirming care, the rule would jeopardize recipients’ best interests, compromise quality of care, and place vulnerable youth at heightened risk of harm. Human Rights Watch is concerned that the proposed rule insufficiently acknowledges the many reasons why gender-affirming care is recognized as best-practice medical care, why it is beneficial and potentially even life-saving to many young people, and how the proposed rule would jeopardize the right to health as well as the freedom from discrimination under international human rights law.
The proposed rule mischaracterizes gender-affirming medical care by referring to it as “sex-rejecting procedures.” It defines such procedures as “any pharmaceutical or surgical intervention that attempts to align a child’s physical appearance or body with an asserted identity that differs from the child’s sex” by either: (1) “intentionally disrupting or suppressing the normal development of natural biological functions, including primary or secondary sex-based traits”; or (2) “intentionally altering a child’s physical appearance or body, including amputating, minimizing, or destroying primary or secondary sex-based traits such as the sexual and reproductive organs.”[38]
In contrast, major medical organizations in the US recognize gender-affirming care as a range of social, psychological, behavioral, and medical interventions that can support transgender people’s health and wellbeing.[39] The World Health Organization has defined gender-affirming care as a range of interventions “designed to support and affirm an individual’s gender identity” when it conflicts with the gender assigned at birth.[40]
The clinically significant distress associated with this incongruence between one’s gender identity and one’s sex assigned at birth is referred to as “gender dysphoria.” Studies have shown that gender dysphoria is linked to higher rates of depression, anxiety, and suicidal ideation.[41] Many young people have powerfully testified to the significant mental health challenges they face as a result of gender dysphoria.[42]
Kai, a 14-year-old, transgender boy interviewed by Human Rights Watch described his experience with gender dysphoria:
“I've had suicidal ideation almost all of my life. I remember even as a 5-year-old having feelings of worthlessness and [thinking] why am I even alive? And more so to the point of having bad gender dysphoria, I don't even recognize the person I see in the mirror. Why should I even live this life that isn't mine?” [43]
Riley, a 26-year-old transman, described how his mother came to understand his dysphoria through her own experience with breast cancer treatment:
“She had to have the entirety of one breast and then half of the other removed... And she actually came up to me several months after her surgery and she's like, I may not understand exactly how you feel regarding dysphoria, but I think I have some understanding of what it feels like. And she described it as a feeling of intense discomfort that's kind of like a dull ache and how it lingers for a long period of time”
Many transgender young people are also subject to discrimination and harassment because of the incongruity between their deeply held gender identity and their secondary sex characteristics, and gender-affirming care can help outwardly align one’s physical characteristics with their gender identity and expression.
Because of gender dysphoria and social discrimination,[44] transgender young people face elevated risks of adverse mental health outcomes compared to non-transgender youth, including depression, anxiety, self-harm, and suicidality. Transgender youth compared with non-transgender youth have been found to have higher rates of depression (50 percent vs. 20 percent), anxiety (26 percent vs. 10 percent), and self-harm (17 percent vs. 4 percent).[45] A 2022 survey of more than 80,000 transgender people in the United States found that 78 percent of respondents had considered suicide and 40 percent had attempted suicide, with youth reporting the highest levels of serious psychological distress.[46] The survey also found that transgender people of color reported higher rates of suicidal thoughts and behaviors than their white counterparts.[47]
Alleviating this incongruence can thus be essential for transgender young people’s mental and physical health. In many instances, the ability to obtain gender-affirming care can meaningfully alleviate gender dysphoria, either by delaying the onset of physical characteristics that are inconsistent with a young person’s gender identity or, in some instances, by assisting in the development of physical characteristics that are consistent with a young person’s gender identity. Both quantitative and qualitative research have shown that this alignment can produce beneficial outcomes for many transgender youth and reduce mental health stressors.[48]
In an interview with Human Rights Watch, for example, Grace described a positive transformation in her 18-year-old son. Before starting gender-affirming care, he would cry when he saw his reflection in the mirror, she said. She recalled the impact of gender-affirming care:
“Shortly after [he started] testosterone, I walked by and he was in the bathroom grinning, grinning at himself [in the mirror] like an idiot. And I'm like, ‘What are you doing?’ And he said, ‘I finally feel like myself.’”[49]
By contrast, evidence from states that have enacted bans on gender-affirming care demonstrates the predictable consequences of policies that disrupt access to care. Currently, 27 states have enacted bans on gender-affirming care for transgender youth. These bans function in practice much like the proposed rule would, by eliminating access to best-practice medical care through legal restriction. Among the families Human Rights Watch interviewed, parents and young people described seven instances of attempted suicide or suicidal ideation linked to transphobia, and, in some cases, they described these as being directly associated with the enactment or threat of a ban on gender-affirming care. Three of these suicide attempts resulted in hospitalization. Interviewees also reported worsening depression, heightened anxiety, increased self-harm, and social withdrawal following the loss of access to care.[50]
Mylie, a 17-year-old transgender girl, described the experience of losing access to gender-affirming care:
“Losing the thing that's making you yourself and that's allowing you to express yourself to the community is a very scary feeling. And my mental health had severely dropped during that time… I had become less social. I had not been doing my schoolwork. I didn't want to go out of my room. I didn't eat as much…. It was basically a loss of everything, motivation…. It had been making me fear that I've only had so much time left to show my true self.”[51]
Following the enactment of her state’s ban, Mylie attempted suicide twice. Her mother, Sarah, described the family’s fear and the immediate shift in Mylie’s mental health:
“There were times of me having to sit in the hallway of her bedroom, not wanting to leave her alone, like her being on the bathroom floor and crying. This is stuff that we never had before.”[52]
Rachel, the mother of 18-year-old Sophia, described how her state’s ban on gender-affirming care severely harmed her daughter’s mental and physical health. Before the ban, Sophia received gender-affirming care in a careful and gradual manner with doctors monitoring her development closely. Sophia’s mental health improved in the first months of treatment. When her state enacted a ban she lost access to this treatment locally.
Rachel said Sophia’s mental health sharply deteriorated during this time. Sophia withdrew from school and began self-harming. Sophia was hospitalized for a week after expressing she had plans to attempt suicide.[53]
During Sophia’s hospitalization, she missed 14 doses of her hormone regimen. Sophia reported heightened anxiety and distress during this period, questioning how she could recover while being denied medication that had helped stabilize her mental and physical wellbeing.[54]
Amelia, the mother of Natalie, a young transgender girl living in a state with a ban in effect, described the distress her daughter experienced at the prospect of being forced through puberty without access to appropriate medical care:
“I can't imagine forcing my child to go through development as a man and then have to reverse it later. To her, it would be agony. I mean, she's so nervous that she's going to get facial hair. She's like, ‘I really just don't want to have facial hair. When is that going to happen? I don't want to look like a boy.’ And just the thought of making her go through that really is very distressing for her, as distressing as it is for me when there is a treatment out there that could help her develop the way that she wants to be seen, in the way that she feels inside.”[55]
The experiences of these young people and families illustrate the foreseeable harms of policies that sever transgender young people from medically necessary care. By cutting off Medicaid and CHIP coverage for this evidence-based care, the proposed rule would interrupt treatment, intensify dysphoria, and increase the risk of serious mental and physical health harms for transgender young people who rely on these programs.
III. The Proposed Rule Would Disproportionately Burden Low-Income and Rural Families
The proposed rule would disproportionately harm low-income families who rely on Medicaid and CHIP to access essential health services. Nearly half of all children in the US receive health coverage through Medicaid or CHIP. Eliminating coverage for gender-affirming care under these programs would impose severe financial strain on families who continue to seek medically necessary care for their children, leaving them with few options beyond paying out of pocket or forgoing care altogether.
Human Rights Watch’s research has documented that when families must seek gender-affirming care without adequate health coverage, even routine components of care can become prohibitively expensive.[56] These costs fall especially heavily on families in rural areas, who may already face limited provider availability and significant travel burdens and, who due to state bans, are often forced to seek care out of state.
Janet, the mother of a 15-year-old transgender boy living in a state with a ban in effect, described these challenges. Although her family was able to locate an out-of-state provider, their insurance company denied coverage for her son’s medications due to the gender dysphoria diagnosis.[57] The out-of-pocket cost was $4,500 every six months. While Janet ultimately secured a partial coverage solution, the medication still cost $600. These financial barriers and administrative delays caused her son to miss a scheduled dose of puberty blockers, triggering the resumption of puberty:
“He started developing again—his breasts—and that was upsetting…. [It] was mentally taxing on him seeing those physical changes because the puberty blocker paused [them]. And seeing those changes happen again, it was really upsetting to him. He's like, ‘Mom, my breasts started growing. Mom, I started my period again.’ I know that did not help his mental health.”[58]
Restrictions on coverage are already widespread. Currently, twelve states prohibit Medicaid coverage for transgender youth seeking gender-affirming care, and ten of these states extend this exclusion to all transgender people regardless of age.[59] Maya, a civil rights attorney, has witnessed the impact of these restrictions: after her state barred Medicaid coverage for gender-affirming care, she observed families of transgender young people without insurance coverage being quoted costs of up to $26,000 every three months for puberty blockers.[60]
By prohibiting federal Medicaid and CHIP funds for gender-affirming care nationwide, the proposed rule would deepen inequities by conditioning access to medically necessary care on family income, geography, and the availability of private resources. It would effectively force low-income families to choose between financial hardship or the denial of care, an outcome fundamentally inconsistent with the purpose of Medicaid and CHIP and with the government’s obligations to ensure nondiscriminatory access to healthcare.
Conclusion
The proposed rule would cut coverage to gender-affirming care for vulnerable young people, putting them in harm’s way. The rule mischaracterizes the efficacy and integrity of gender-affirming care and instead relies on ideology rather than evidence to justify its policy. If enforced, the rule would act as a nationwide mechanism to functionally deny medically necessary care to many transgender young people. Rather than advancing the “best interests” of Medicaid and CHIP beneficiaries or promoting quality of care,[61] the rule would predictably destabilize young people’s health, worsen mental and physical health outcomes, and deepen existing inequities.
The proposed rule is also inconsistent with the purpose and structure of Medicaid and CHIP, which exist to ensure access to essential health services for young people and low-income individuals. By prohibiting federal funding for medically indicated care for transgender youth, the rule would entrench discrimination and exclusion and subject vulnerable young people to foreseeable, preventable harm.
We request that CMS and HHS take these comments into account and withdraw the proposed rule in its entirety.
Please contact us if you have questions regarding our comments. Thank you for your consideration.
Sincerely,
Yasemin Smallens
Acting Researcher
LGBT Rights Division
Human Rights Watch
[1] Human Rights Watch, “‘They’re Ruining People’s Lives’ Bans on Gender-Affirming Care for Transgender Youth,” June 3, 2025, https://www.hrw.org/report/2025/06/03/theyre-ruining-peoples-lives/bans-on-gender-affirming-care-for-transgender-youth.
[2] Medicaid Program: Prohibition on Federal Medicaid and Children’s Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children, 90 Fed. Reg. 59441 (Dec. 19, 2025) (to be codified at 42 C.F.R. pts. 430, 440, 441, 457).
[3] Ibid.
[4] Social Security Act, Title XIX, 42 U.S.C. §§ 1396, https://www.ssa.gov/OP_Home/ssact/title19/1900.htm (accessed February 8, 2026).
[5] Social Security Act, Title XXI, 42 U.S.C. §§ 1397aa, https://www.ssa.gov/OP_Home/ssact/title21/2100.htm (accessed February 8, 2026); 42 C.F.R. pt. 457,
[6] KFF, “Monthly Child Enrollment in Medicaid and CHIP,” KFF State Health Facts, https://www.kff.org/medicaid/state-indicator/total-medicaid-and-chip-child-enrollment/ (accessed February 8, 2026).
[7] International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976
[8] UN Committee on Economic, Social and Cultural Rights, General Comment No. 20: Non-Discrimination in Economic, Social and Cultural Rights, U.N. Doc. E/C.12/GC/20, July 2, 2009, para. 32.
[9] CESCR, General Comment No. 14, The Right to the Highest Attainable Standard of Health, U.N. Doc. E/C.12/2000/4 (2000).
[10] Ibid.
[11]International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), 999 U.N.T.S. 171, entered into force March 23, 1976, art. 26.
[12] Office of the United Nations High Commissioner for Human Rights, Born Free and Equal: Sexual Orientation, Gender Identity and Sex Characteristics in International Human Rights Law, New York and Geneva: United Nations, 2019, https://www.ohchr.org/Documents/Publications/BornFreeAndEqualLowRes.pdf (accessed November 26, 2024).
[13] Stephanie L. Budge, Roberto L. Abreu, Ryan E. Flinn, Kelly L. Donahue, Rebekah Estevez, Christy L. Olezeski, Jessica M. Bernacki, Sebastian Barr, Jay Bettergarcia, Richard A. Sprott, and Brittany J. Allen, “Gender Affirming Care Is Evidence Based for Transgender and Gender-Diverse Youth,” Journal of Adolescent Health, 75, no. 6 (December 2024): 851–853, accessed February 15, 2026, doi:10.1016/j.jadohealth.2024.09.009.
[14] Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen, “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” The Journal of Clinical Endocrinology & Metabolism, 102(11) (2017): 3869–3903, accessed November 19, 2924, doi.10.1210/jc.2017-01658.
[15] E. Coleman, A. E. Radix, W. P. Bouman, et. al, “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” International Journal of Transgender Health, 23(sup1) (2022): S1-S259, accessed November 19, 2024, doi: 10.1080/26895269.2022.2100644. 4.
[16] “AMA to states: Stop interfering in health care of transgender children,” American Medical Association press release, Chicago, April 26, 2021, https://www.ama-assn.org/press-center/press-releases/ama-states-stop-interfering-health-care-transgender-children (accessed November 19, 2024). On February 5, 2026 the American Medical Association (AMA) issued a statement indicating that surgical interventions to treat gender dysphoria in transgender youth should generally be deferred until patients reach adulthood. However, the association reiterated its support for evidence-based, non-surgical interventions, which include puberty-delaying medications and hormone therapies, to treat dysphoria in transgender youth. See more: Azeen Ghorayshi, “Doctors’ Group Endorses Restrictions on Gender-Related Surgery for Minors,” New York Times, February 4, 2026, https://www.nytimes.com/2026/02/04/health/gender-surgery-minors-ama.html (accessed February 12, 2025).
[17] “AAP reaffirms gender-affirming care policy, authorizes systematic review of evidence to guide update,” American Academy of Pediatrics policy statement, August 4, 2023, https://publications.aap.org/aapnews/news/25340/AAP-reaffirms-gender-affirming-care-policy?autologincheck=redirected (accessed November 19, 2024)
[18] “AACAP Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse Youth,” American Academy of Child and Adolescent Psychiatry, November 8, 2019, https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx (accessed November 19, 2024).
[19] Per the Endocrine Society’s guidelines, adolescents are eligible for treatment with GnRH agonists (puberty-delaying medications) once the adolescent has provided informed consent and—particularly where they have not reached the legal age of medical consent under applicable law—their parents, guardians, or other caregivers have also consented and are actively involved in supporting the adolescent throughout the treatment process. Wylie C Hembree, Peggy T Cohen-Kettenis, et. All, “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.”
[20] Human Rights Watch, “‘They’re Ruining People’s Lives’ Bans on Gender-Affirming Care for Transgender Youth,” pg. 40.
[21] Mayo Clinic Staff, “Puberty Blockers for Transgender and Gender-Diverse Youth,” Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/gender-dysphoria/in-depth/pubertal-blockers/art-20459075 (accessed November 19, 2024); Rosemary C. Roden, “Reversible Interventions for Menstrual Management in Adolescents and Young Adults with Gender Incongruence,” Therapeutic Advances in Reproductive Health 17 (2023): accessed November 19, 2024,
doi:10.1177/26334941231158251.
[22] Jack L Turban, Dana King, Jeremi M Carswell, et al., “Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation,” Pediatrics, 145(2) (2022): e20191725, accessed November 19, 2024, doi:10.1542/peds.2019-1725; Diana M Tordoff, Jonathon W Wanta, Arin Collin, “Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care,” JAMA Network, 5(2) (2022): e220978, accessed November 19, 2024.
[23] Hormone therapies for youth are generally considered safe; however, like any medical intervention, they carry potential risks. Further information on the effectiveness and safety of these treatments, within the context of medical best practices, can be found here: RAND, Alex R. Dopp, Allison Peipert, John Buss, Robinson De Jesús-Romero, Keytin Palmer, and Lorenzo Lorenzo-Luaces, Interventions for Gender Dysphoria and Related Health Problems in Transgender and Gender-Expansive Youth: A Systematic Review of Benefits and Risks to Inform Practice, Policy, and Research (Santa Monica: 2024), https://www.rand.org/pubs/research_reports/RRA3223-1.html (accessed January 14, 2025); Hane Htut Maung, “Gender Affirming Hormone Treatment for Trans Adolescents: A Four Principles Analysis,” Bioethical Inquiry, 21 (2024): 345–363, https://doi.org/10.1007/s11673-023-10313-z, pp. 351–353.
[24] Patrick Boyle, “What is Gender-Affirming Care? Your Questions Answered,” Association of America Medical Colleges News, April 12, 2022, https://www.aamc.org/news/what-gender-affirming-care-your-questions-answered (accessed November 20, 2024).
[25] American Psychological Association, "Guidelines for psychological practice with transgender and gender nonconforming people," American Psychologist 70, no. 9 (2015): 849, accessed November 20, 2024, doi:10.1037/a0039906.
[26] US Food and Drug Administration (FDA), "LUPRON DEPOT-PED (leuprolide acetate for depot suspension)," FDA Approved Drug Products, revised July 2017, https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020263s042lbl.pdf (accessed November 20, 2024).
[27] Dannie Dai, Brittany M. Charlton, Elizabeth R. Boskey, et al., “Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US,” JAMA Network (2024): e2418814, accessed January 14, 2025, doi:10.1001/jamanetworkopen.2024.18814.
[28] Ibid.
[29] Jack L. Turban, Dana King, Jeremi M. Carswell, et al., “Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation,” The Lancet Child & Adolescent Health, 7 (2023): 32–40, accessed January 14, 2025, doi:10.1016/S2352-4642(22)00254-1.
[30] Erin E. Cooney, Luke Muschialli, Ping Teresa Yeh, Connor Luke Allen, Dean J. Connolly, Rose Pollard Kaptchuk, et al., “Provision of Gender-Affirming Care for Trans and Gender-Diverse Adults: A Systematic Review of Health and Quality of Life Outcomes, Values and Preferences, and Costs,” The Lancet, 88, no. 103458 (October 2025), https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(25)00390-6/fulltext, accessed February 8, 2026, doi: 10.1016/j.eclinm.2025.103458; Diane M. Tordoff, Jennifer W. Wanta, Avery Collin, et al., “Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care,” JAMA Network, 5 (2022): e220978, accessed January 14, 2025, doi:10.1001/jamanetworkopen.2022.0978; Jack L. Turban, Dana King, Jeremi M. Carswell, et al., “Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation,” Pediatrics, 145 (2020), accessed January 14, 2025, doi:10.1542/peds.2019-172; Jack L. Turban, Dana King, Jennifer Kobe, et al., “Access to Gender-Affirming Hormones During Adolescence and Mental Health Outcomes Among Transgender Adults,” PLoS One, 17 (2022): e0261039, accessed January 14, 2025, doi:10.1371/journal.pone.0261039.
[31] Human Rights Watch, “‘They’re Ruining People’s Lives’ Bans on Gender-Affirming Care for Transgender Youth,” pg. 27.
[32] Ibid, pg. 28.
[33] Ibid.
[34] Ibid. 25-26; Luca Borah, Laura Zebib, Hayley M. Sanders, Maxence Lane, Daphna Stroumsa, and Kevin C. Chung, “State Restrictions and Geographic Access to Gender-Affirming Care for Transgender Youth,” JAMA, 330(4) (2023): 375–378, accessed March 17, 2025, doi:10.1001/jama.2023.11299.
[35] Social Security Act § 1902(a)(19), 42 U.S.C. § 1396a(a)(19).
[36] Social Security Act § 1902(a)(30)(A), 42 U.S.C. § 1396a(a)(30)(A).
[37] Social Security Act § 2101(a), 42 U.S.C. § 1397aa(a).
[38] Medicaid Program: Prohibition on Federal Medicaid and Children’s Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children, 90 Fed. Reg. 59441, 59442 (Dec. 19, 2025), https://www.federalregister.gov/documents/2025/12/19/2025-23464 (accessed February 8, 2026).
[39] Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen, “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” The Journal of Clinical Endocrinology & Metabolism, 102(11) (2017): 3869–3903, accessed November 19, 2924, doi.10.1210/jc.2017-01658; E. Coleman, A. E. Radix, W. P. Bouman, et. al, “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” International Journal of Transgender Health, 23(sup1) (2022): S1-S259, accessed November 19, 2024, doi: 10.1080/26895269.2022.2100644. 4; “AMA to states: Stop interfering in health care of transgender children,” American Medical Association press release, Chicago, April 26, 2021, https://www.ama-assn.org/press-center/press-releases/ama-states-stop-interfering-health-care-transgender-children (accessed November 19, 2024); “AAP reaffirms gender-affirming care policy, authorizes systematic review of evidence to guide update,” American Academy of Pediatrics policy statement, August 4, 2023, https://publications.aap.org/aapnews/news/25340/AAP-reaffirms-gender-affirming-care-policy?autologincheck=redirected (accessed November 19, 2024); “APA Policy Statement on Affirming Evidence-Based Inclusive Care for Transgender, Gender Diverse, and Nonbinary Individuals, Addressing Misinformation, and the Role of Psychological Practice and Science,” American Psychological Association, February 2024, https://www.apa.org/about/policy/transgender-nonbinary-inclusive-care (accessed November 19, 2024); “AACAP Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse Youth,” American Academy of Child and Adolescent Psychiatry, November 8, 2019, https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx (accessed November 19, 2024).
[40] World Health Organization, “Gender Incongruence and Transgender Health in the ICD,” https://www.who.int/standards/classifications/frequently-asked-questions/gender-incongruence-and-transgender-health-in-the-icd (accessed February 8, 2026).
[41] Diane M. Tordoff, Jennifer W. Wanta, Avery Collin, et al., “Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care,” JAMA Network, 5 (2022): e220978, accessed January 14, 2025, doi:10.1001/jamanetworkopen.2022.0978; Vicky Holt, Elin Skagerberg, and Michael Dunsford, “Young People with Features of Gender Dysphoria: Demographics and Associated Difficulties,” Clinical Child Psychology and Psychiatry, 21, no. 1 (January 2016): 108–118, accessed February 8, 2026, doi:10.1177/1359104514558431.;
[42] Human Rights Watch, “‘They’re Ruining People’s Lives’ Bans on Gender-Affirming Care for Transgender Youth,” pg. 23.
[43] Ibid.
[44] Jamie M. White Hughto, Sari L. Reisner, and John E. Pachankis, “Transgender Stigma and Health: A Critical Review of Stigma Determinants, Mechanisms, and Interventions,” Social Science & Medicine, 147 (December 2015): 222–231, accessed February 8, 2026, doi:10.1016/j.socscimed.2015.11.010.
[45] Sari L Reisner, Ralph Vetters, M Leclerc, et. al, “Mental Health of Transgender Youth in Care at an Adolescent Urban Community Health Center: A Matched Retrospective Cohort Study,” Journal of Adolescent Health (2015): 274-9, accessed November 19, 2024, doi: 10.1016/j.jadohealth.2014.10.264.
[46] Ankit Rastogi, Leesh Menard, Gabe H. Miller, Will Cole, Daniel Laurison, Josie Caballero, Sinéad Murano-Kinney, and Rodrigo Heng-Lehtinen, Health and Wellbeing: A Report of the 2022 U.S. Transgender Survey (Advocates for Transgender Equality, June 2025), https://ustranssurvey.org/download-reports/.
[47] Ibid.
[48] Diane M. Tordoff, Jennifer W. Wanta, Avery Collin, et al., “Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care,” JAMA Network, 5 (2022): e220978, accessed January 14, 2025, doi:10.1001/jamanetworkopen.2022.0978; Jack L. Turban, Dana King, Jeremi M. Carswell, et al., “Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation,” Pediatrics, 145 (2020), accessed January 14, 2025, doi:10.1542/peds.2019-172; Jack L. Turban, Dana King, Jennifer Kobe, et al., “Access to Gender-Affirming Hormones During Adolescence and Mental Health Outcomes Among Transgender Adults,” PLoS One, 17 (2022): e0261039, accessed January 14, 2025, doi:10.1371/journal.pone.0261039; Diane M. Tordoff, Jennifer W. Wanta, Avery Collin, et al., “Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care.”
[49] Human Rights Watch, “‘They’re Ruining People’s Lives’ Bans on Gender-Affirming Care for Transgender Youth,” pg 25.
[50] Ibid., pg. 3.
[51] Ibid., pg. 29
[52] Ibid.
[53] Ibid., pg. 40.
[54] Ibid.
[55] Ibid., pg. 33
[56] Ibid., pg. 32
[57] Ibid., pg. 37.
[58] Ibid.
[59] Movement Advancement Project, “Medicaid Coverage of Transgender-Related Health Care,” https://www.lgbtmap.org/equality-maps/medicaid (accessed February 8, 2026).
[60] Human Rights Watch, “‘They’re Ruining People’s Lives’ Bans on Gender-Affirming Care for Transgender Youth,” pg. 4.
[61] Social Security Act § 1902(a)(19), 42 U.S.C. § 1396a(a)(19).
