The Real-World Harm This Ban Would Cause—and What We Should Do Instead

Part 3 of 3

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When politicians debate policy, it’s easy to forget that real families are affected by every decision. So let me be direct about what this federal rule would actually mean for the young people and families I work with—and then explain what better options exist if policymakers genuinely want to improve care quality rather than eliminate it.

These Are Not Elective Procedures

For many transgender youth, gender-affirming medical interventions are not elective. They are medically necessary treatments for a recognized clinical condition. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), and when it is persistent and associated with significant functional impairment, it warrants treatment, just as other conditions producing significant distress and impairment do.

I have seen the suffering that untreated gender dysphoria causes. I have also seen the transformative impact that appropriate, carefully evaluated, family-supported gender-affirming care can have. The families I work with don’t make these decisions casually. They have gone through comprehensive evaluations lasting months, sometimes years. They have consulted multiple specialists. They have talked to trusted spiritual advisors. They have thought, prayed, and deliberated. With one politically-motivated rule, the federal government would sweep aside every one of those careful, deeply personal decisions made by families in consultation with their doctors.

Mental Health Consequences Are Real and Measurable

Transgender youth already experience disproportionately high rates of depression, anxiety, and suicidal ideation—not because of anything inherent to being transgender, but because of minority stress , stigma, and lack of acceptance. A comprehensive review in the Annual Review of Clinical Psychology confirms that these elevated rates of psychological distress are driven primarily by minority stress and that family support and gender-affirming care are among the most important protective factors available . The research is clear: access to gender-affirming care is protective against these outcomes. Denial of care is associated with worse outcomes.

A prospective study in JAMA Network Open found a 73% reduction in suicidality over 12 months among youth who received gender-affirming care compared to those who wanted but could not access it . A four-site, NIH-funded prospective study published in the New England Journal of Medicine further found that these mental health benefits—including reduced depression and improved life satisfaction—were sustained over two years of follow-up . A large population-based study of over 20,000 transgender adults found that those who had accessed pubertal suppression during adolescence had 70% lower odds of lifetime suicidal ideation compared to those who wanted it but could not access it . This proposed rule would create a federal barrier to exactly that kind of care.

The language of the proposed rule itself causes harm. Terms like “mutilation” and “castration”—used to describe standard medical procedures endorsed by every reputable professional medical organization in the country—are not neutral clinical descriptions. They are deliberate provocations. This is the language of bullying, and that is exactly what this is: people in positions of power using the machinery of the federal government to demean, stigmatize, and intimidate vulnerable children and the families and clinicians who care for them. When the government enshrines this kind of cruelty in official policy documents, it doesn’t just reflect bias—it weaponizes it, lending the full authority of the state to harassment and hostility. Research on minority stress makes clear that this kind of environment directly worsens mental health outcomes for transgender young people . These are not abstract harms. This language targets real children, and it hurts them.

What Happens to Kids Already in Treatment

One of the most overlooked harms of this rule would fall on youth who are already receiving care. Thousands of young people are currently mid-treatment at hospitals that participate in Medicare and Medicaid. This rule would abruptly sever those established therapeutic relationships and interrupt ongoing care.

Abruptly withdrawing effective treatment—not because the treatment stopped working, not because the provider or parent believes it is no longer appropriate, but because of a political decision—causes real psychological harm. Youth who have already begun puberty suppression or hormone therapy would face the destabilizing experience of having their care arbitrarily removed. Research examining transgender adolescents’ and their families’ experiences confirms that these families deeply value their relationships with trusted providers and rely on the continuity of collaborative care . This rule would sever those relationships by political fiat. A survey of 103 providers from all 50 states found that nearly all believed legislation banning gender-affirming care would worsen mental health and increase suicide risk among their patients, with many describing how such bans would force clinic closures and place providers in the impossible position of choosing between their ethical obligations and their legal exposure .

And again: wealthy families might be able to find cash-pay alternatives. Low-income families will simply have nowhere to turn.

Care Is Already Carefully Safeguarded

A recurring implication in arguments for this kind of ban is that gender-affirming care is provided hastily or without appropriate evaluation. That is false, and it misrepresents how this care is actually delivered.

Current clinical standards—as outlined by WPATH, the Endocrine Society, and other professional bodies—already include extensive safeguards :

• A comprehensive biopsychosocial assessment involving both medical and mental health professionals
• Documentation that gender diversity or incongruence is marked and sustained over time
• Confirmation that the adolescent demonstrates the emotional and cognitive maturity required to provide informed consent or assent
• Assessment of any mental health concerns that might interfere with diagnostic clarity or capacity to consent, addressed sufficiently so that treatment can be provided optimally
• Informed consent covering the effects of treatment on reproduction and available options to preserve fertility, with parental or guardian involvement unless determined harmful or not feasible
• A staged approach: puberty blocking agents (requiring Tanner stage 2) precede hormonal treatments, which precede surgical interventions
• At least 12 months of gender-affirming hormone therapy before most surgical procedures, unless hormones are not desired or medically contraindicated
• Ongoing monitoring of physical health, hormone levels, and psychosocial functioning throughout treatment

The families I work with don’t encounter a fast-food model of care. They encounter a rigorous, deliberate, collaborative process. The low rates of regret documented in the research literature—below 1% for surgical procedures , around 2% among those who accessed care as adolescents —are in large part because of these safeguards.

What Good Policy Would Actually Look Like

If policymakers have genuine concerns about care quality—rather than an ideological objection to transgender youth existing—there are evidence-based alternatives that address quality without eliminating access:

Require adherence to established clinical guidelines. Hospitals providing gender-affirming care could be required to follow guidelines from the Endocrine Society, WPATH, the American Academy of Pediatrics, or other professional bodies as a condition of participation. Clinicians from Boston Children’s Hospital’s Gender Multispecialty Service have argued directly that the appropriate policy response to legislative threats is to ensure that care meets the rigorous, multidisciplinary criteria already established by professional standards bodies—and that youth who meet those criteria should not be denied access to evidence-based treatment .

Mandate comprehensive informed consent documentation. Require that informed consent processes meet defined standards and that decision-making is thoroughly documented. The SOC-8 specifies detailed informed consent requirements, covering discussion of reproductive effects and fertility preservation, as a prerequisite for all gender-affirming interventions (Coleman et al., 2022).

Require multidisciplinary team involvement. Many programs already do this; making it a universal requirement would address concerns about unilateral or insufficiently evaluated decisions. The SOC-8 explicitly identifies multidisciplinary assessment—spanning medical providers, mental health professionals, and support services—as the standard model of care for gender-diverse youth, and requires that this collaborative approach be in place before hormonal or surgical interventions are initiated .

Support high-quality research. Rather than banning treatments, fund the longitudinal research that would improve clinical protocols and outcome assessment. A systematic review in eClinicalMedicine, commissioned to inform a World Health Organization (WHO) guideline development process, concluded that evidence from prospective controlled studies would enhance the evidence base and more comprehensively document the impact of gender-affirming care on health outcomes—explicitly recommending continued research rather than restriction of care .

Develop quality metrics. Create measurable standards for programs providing gender-affirming care, and tie participation to demonstrated quality. A technical expert panel convened by the RAND Corporation (a nonprofit research organization) and Brown University specifically examined quality measurement for transgender care, identifying key domains such as hormone monitoring and mental health screening as ripe for quality metric development .

Require provider training. Ensure that providers working with gender-diverse youth have appropriate training in evidence-based approaches. Research consistently documents that provider knowledge gaps and implicit bias are significant barriers to quality care for transgender patients, and that training interventions are effective in improving provider competence and patient outcomes .

Any of these alternatives would meaningfully address concerns about care quality while preserving access to necessary medical treatment, respecting the clinical judgment of qualified professionals, and honoring the fundamental right of families to make healthcare decisions for their children.

The Bottom Line

This proposed rule does not protect children. It harms them—disproportionately the most vulnerable ones, from the lowest-income families, in the most underserved communities.

It substitutes political ideology for medical expertise. It contradicts the consensus of every reputable medical and mental health organization in the United States. It relies on a government review that was produced without peer review, under political pressure, in 90 days, by anonymous authors—a review that itself depends heavily on the Cass Report, which has been subjected to serious methodological critique in peer-reviewed scientific literature , and which is now the subject of an independent investigation by the British Medical Association.

Medical decisions for children belong with families and their healthcare providers—not with federal bureaucrats who have never met those children. The appropriate response to complexity in medical evidence is informed consent, shared decision-making, and continued research. Not a blanket ban.

I urge CMS to withdraw this proposed rule and instead engage with the medical community on approaches that actually improve care quality while respecting both the evidence and the families who depend on it.

Robert P. Allred, PhD, ABPP is a psychologist board certified in addiction psychology, with specialized training and clinical experience in treating transgender and gender-diverse youth.

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