12/14/24

How a Decades-Old Loophole Lets Billionaires Like Musk, Avoid Medicare Taxes

by Paul Kiel

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

Series: The Secret IRS Files:Inside the Tax Records of the .001%

More in this series

Reporting Highlights

  • Tax Dodge: Most working Americans have to pay Medicare taxes, but some of the richest figures on Wall Street have found a way to opt out, a ProPublica investigation found.
  • Accidental Loophole: Nearly 50 years ago, Congress tried to fix one financial abuse but unwittingly created an obscure loophole that these billionaires exploit to avoid Medicare taxes.
  • Battling Abuse: The IRS only recently got tough on people it viewed as abusing the loophole, but it is unclear if the agency will be able to end the practice.

These highlights were written by the reporters and editors who worked on this story.

For most working Americans, paying their share of the taxes that fund Medicare is an unavoidable fact of life. It’s so automatic for many workers that they may not even realize it takes a bite out of every paycheck. In theory, everyone is required to contribute to the country’s health insurance program for seniors, no matter how poor or rich, from cashiers to CEOs.

Not on Wall Street. There, some of the most powerful people in finance found a way to opt out.

The trove of tax records behind ProPublica’s “Secret IRS Files” series contains plenty of examples of billionaire financiers who avoided Medicare tax despite earning huge amounts from their companies. In 2016, Steve Cohen, the owner of the New York Mets, paid $0. So did Stephen Schwarzman, head of the investment behemoth Blackstone. Bill Ackman, the headline-grabbing hedge fund manager, was able to shield almost all his income from the tax.

How do they do it? Business owners, like any self-employed person, whether they’re a freelance Uber driver or a hedge fund manager, have the responsibility to declare their self-employment earnings on their tax returns. Indeed, the vast majority of small-business owners have no choice but to do so and pay the same taxes that wage earners pay, including Medicare.

But high-priced tax advisers, wielding a once-obscure bit of the tax code, found a way to make that obligation vanish. By carefully channeling profits through a company in a way that invokes that obscure provision, even a Steve Cohen, with a tax return showing he received hundreds of millions in profits from his hedge fund, can exempt that income from Medicare tax.

The three billionaires contacted for this article said they followed the law as written. They also pointed to the fact that they paid substantial income tax, which for them carries a much higher rate. Medicare tax is 2.9% for most people and 3.8% for high earners.

But these maneuvers by the rich hasten Medicare’s future crisis. Sometime in the 2030s, the program’s trust fund is due to run dry. Closing the loophole, along with eliminating other ways around the tax for wealthy business owners, could raise more than $250 billion over 10 years for Medicare, according to recent government estimates.

Over the past three years, ProPublica has mined the tax records of the rich to detail the many ways they avoid taxes. We’ve focused on basic structural features of the U.S. system that advantage them. We’ve uncovered maneuvers of questionable legality that seem to have escaped the notice of the IRS. The Medicare tax loophole occupies a gray area. The IRS definitely knows about it, but it’s unclear if the agency will be able to stop it.

The potential of the loophole first surfaced in the 1990s, and the IRS soon expressed the view that active business owners shouldn’t be allowed to exploit it. It was only in recent years, however, that the agency got tough. Today, the IRS continues to battle what it considers a serious abuse, waging a rare, long-shot campaign to prevent some of the nation’s wealthiest citizens from using the loophole.

The story of how America’s richest financiers avoid paying Medicare tax gives unique insight into the peculiar, messy way taxes work in the U.S. No one set out to create the loophole when it first entered the tax code in 1977. But a series of seemingly unrelated policy changes, together with a revolution in how American businesses are structured, conspired to deliver a major tax advantage to the wealthy. On Capitol Hill, interest groups have successfully defended that advantage, branding any effort to close the loophole as a tax hike on Main Street businesses.

Approaching its 50th birthday, the loophole, for now, lives on.

Fixing One Problem, Creating Another

Over the 2010s, years of budget cuts sliced deep into the IRS’ enforcement muscle. Audits, especially those of the wealthy and corporations, plummeted. In response, agency leaders decided to conduct a kind of triage and focus the IRS’ dwindling might on the most pressing and addressable problems. Among the agency’s early priorities was to curb the widespread use of the Medicare tax loophole.

Beginning in 2018, the agency began hunting for business owners who, in its view, were abusing the law. It launched over 80 audits aimed at hedge funds, private equity firms, consultancies and similar businesses. Cohen’s firm was just the sort of thing the agency was looking for.

Before Cohen became popular as the approachable, gap-toothed, sweater-wearing Mets-fan-in-chief, he was a controversial figure on Wall Street, the inspiration for the legal-risk-taking hedge fund lead character in the Showtime series “Billions.” Cohen made his fortune through his original hedge fund, SAC Capital, known for rapid-fire trades with a remarkable track record. In 2013, SAC pleaded guilty to five criminal counts of securities and wire fraud, agreeing to pay $1.8 billion in penalties and effectively shut itself down. Cohen was not personally charged. Turning the page, he soon formed a new hedge fund, Point72.

The IRS’ audit of Point72 focused on one thing: how the profits had flowed to Cohen. In 2015, his firm earned $125 million from clients, and the money was routed to him through Point72 Asset Management LP.

Those last two letters, which stand for limited partnership, were Cohen’s key to accessing the loophole.

For most of the last century, before hedge funds and private equity firms dominated Wall Street, limited partnerships played a very specific role. They allowed investors, as limited partners, to buy into a business — often oil drilling or real estate development — without the usual risks of ownership like being pursued for the business’s debts.

But by the 1970s, creative uses of limited partnerships proliferated. One variety caught Congress’ attention. Government employees were covered by public pensions and thus were not eligible for Social Security, but brokerages were pitching these employees on limited partnerships as a way around that. The government workers could buy a small share of a business and receive self-employment income that qualified them for future Social Security benefits.

The scheme was condemned by both parties. After all, Social Security was meant to reward people’s labor, not their investments. Only income earned by someone actively running a business should count toward Social Security.

The solution, Congress decided, was to exclude most income earned by limited partners. It wouldn’t count toward self-employment income and, as a result, wouldn’t be subject to self-employment tax, which goes to Social Security and Medicare. As part of a major 1977 Social Security reform bill, this soon became the law.

It seemed like an easy fix. At the time, limited partners were, as a rule, passive investors. The line between the two types of partners that made up a limited partnership was real: General partners ran the business, and limited partners didn’t.

“Limited partners were historically forbidden under state law from getting too involved in the business,” said Susan Hamill, professor of law at the University of Alabama. “If they got involved at all, they would simply be treated as general partners, and the liability shield would be stripped away from them.”

Lawmakers assumed things would continue as they’d always been. They didn’t. The 1977 law, it turned out, had passed at the dawn of a new age, one where limited liability became standard for business owners, not a special condition with strings attached.

A new business structure, the limited liability company, exploded in popularity in the ’90s. LLCs limited the legal liability of all owners regardless of their role. Limited partnerships morphed into something that functioned similarly. After the change, the fact that someone was a limited partner said nothing about what they did for the business. They could be the CEO or a passive investor. It became common for owners to serve as both limited and general partners.

In this new world, the 1977 law was no longer a narrow exclusion. It was a broad grant of tax avoidance to anyone with a canny tax adviser.

Point72 Asset Management LP was part of the trend.

To take advantage of the loophole, Cohen needed to channel his firm’s profits through a limited partner before the money reached him.

One obstacle, it might seem, was that Cohen was one person. How could he partner with himself? That part was simple. A partnership requires at least two partners, but they can be companies or people. Cohen created two business entities, each wholly owned by him. One became the limited partner, the other the general partner.

Over 2015 and 2016, Point72 Asset Management earned $344 million in profits; 99.98% of that went to the limited partner and was declared exempt from Medicare tax. While those profits were subject to the 40% income tax rate (as much as $136 million in tax), Cohen’s returns showed $0 in self-employment income both years, helping him avoid up to $11 million in Medicare tax.

The IRS audited those returns and determined that the full $344 million was self-employment income. Last year, Point72 challenged that finding in court in a case that continues to this day. A spokesperson for Cohen declined to comment, citing the ongoing litigation.

“A Nasty Little Tax Increase”

Almost as soon as LLCs began their rapid spread, IRS officials recognized the possibility of widespread avoidance of self-employment tax. The problem became more urgent after 1993. Since its beginning, Medicare tax had, like Social Security, been capped. But Congress, in need of more revenues to support Medicare, eliminated the cap. Suddenly, avoiding Medicare tax might save a business owner millions of dollars instead of, in 1993, under $4,000.

In 1997, the IRS proposed a rule that would dictate how the 1977 law should be interpreted. A limited partner would mean essentially what it had meant back in 1977, when the term described passive investors. People who worked more than 500 hours (about three months) annually for the business could not be a limited partner under Section 1402(a)(13), the loophole’s place in the tax code.

IRS rule proposals are usually soporific affairs closely watched only by tax practitioners. But in early April 1997, fax machines in Republican congressional offices spat out a message that ended this rule’s obscurity.

The IRS was about “to slip through a nasty little tax increase on America’s partnerships,” the memo read. It was from Steve Forbes, the millionaire magazine publisher and 1996 Republican presidential candidate. He’d centered his self-funded campaign around the idea of a “flat tax,” under which he promised “the IRS would be RIP.” Now he was rallying his party against what he called a “stealth tax increase.”

His message reached Rush Limbaugh, the conservative radio host, who was then at the height of his influence. Soon after Limbaugh mentioned Forbes’ faxed memo on his nationally syndicated show, Speaker of the House Newt Gingrich, a Georgia Republican, called in.

Congress would “intervene directly,” Gingrich promised. “And as you yourself pointed out earlier, we didn’t get elected to raise taxes. We got elected to lower taxes and simplify them and to end the IRS as we know it,” he said.

“Now, folks, that is fast action,” Limbaugh boasted.

A coalition of powerful trade groups hurriedly formed to pressure Congress to follow through on Gingrich’s vow. The rule change would raise taxes by more than $1 billion over the following decade, they estimated, and must be stopped.

The coalition represented businesses that were both small and decidedly not small (among the members were the U.S. Chamber of Commerce and the Securities Industry Association). But their message emphasized the rule’s impact on the “small business community.”

In fact, most small-business owners already paid Medicare and Social Security taxes. Then, as now, the most common form of small business was the simple sole proprietorship, taxspeak for a business with a single, human owner.

By July, the coalition had prevailed. A short provision of a major bill, the Taxpayer Relief Act of 1997, forbade the IRS from issuing any new rule “with respect to the definition of a limited partner” in the next year.

The IRS had been roundly rebuffed. It would be almost two decades before the agency would seriously consider trying again.

In the meantime, the options for business owners to skirt Medicare tax multiplied. New forms of partnerships arose, and the subchapter S corporation, which offered its own loophole around Medicare tax, emerged as an even more popular vehicle. The breadth of the tax avoidance meant that opposition to closing those loopholes would be even fiercer the next time there was a major threat.

“100% Political Fear”

In early 2010, President Barack Obama’s administration and a Democratic Congress were struggling to pass the Affordable Care Act when they hit on a way to help fund it. The proposal boiled down to an expansion of Medicare tax. Whereas before it had only applied to income from work, now, for high earners, it would extend to investment income like dividends and capital gains. The rate would also go from 2.9% to 3.8%.

But, while new forms of income would now be subject to the tax, the proposal intentionally left huge gaps. It wouldn’t touch the ability of business owners to use loopholes to avoid Medicare tax and would even limit their exposure to the new tax on investment income.

Why create a new, complicated tax that favored some forms of income over others, asked Jason Furman, then a member of Obama’s National Economic Council. In a meeting with Obama and his advisers, Furman advocated for a simple, uniform version of the tax that would also close the loophole, he said. The president agreed on the merits, Furman said. But arousing the opposition of the business lobby could endanger the whole bill. It wasn’t worth the risk. “It was 100% political fear,” Furman said.

A monumental health care reform effort like the ACA was already controversial, and members of Congress were looking to get it passed, said Robert Andrews, a former New Jersey Democratic representative and lead negotiator on the bill. They chose the funding option “with the least political risk,” he said.

“This was an ugly compromise, and I think we knew it was an ugly compromise and worth it for the greater good,” Furman said.

Pushing Around the Edges

As the years passed and no legislative fix came, the IRS vacillated on what to do about the limited partner loophole. The Treasury Department decides which tax regulations to pursue, and under the Bush and then the Obama administration, there wasn’t appetite for another bruising fight over a new rule. At the same time, IRS officials decided they couldn’t ignore what they viewed as widespread abuse of Section 1402(a)(13).

They decided on a middle path, said Curt Wilson, who in 2008 became the senior IRS attorney overseeing partnership issues. “We looked for places where we could push around the edges, so to speak,” he said.

This wasn’t a crusade. But in audits, when the opportunity presented itself, the agency cracked down on what it saw as abuse of the loophole. Agents focused on some of the newer forms of partnerships that had sprouted since 1977. LLCs were the prime target.

“We were looking at hedge funds, private equity firms, things like that where there were big dollars,” Wilson said. The goal was to make a splash with a precedent-setting case.

Landing that big case proved elusive. Instead of fighting it out in court, taxpayers were content to privately settle the audits with the IRS’ appeals division, Wilson said. The IRS did its best to send a message, releasing an advisory letter in 2014 to a hedge fund that said the fund’s LLC members didn’t qualify as limited partners. But that wasn’t a binding rule, and it fell short of a headline-grabbing court decision.

What’s more, the IRS risked playing Whac-A-Mole. Even if the agency succeeded in dissuading taxpayers from using the loophole with LLCs, business owners could simply register their business as a limited partnership instead. As the granddaddy of partnerships with limited liability, the LP, the original limited partnership, offered taxpayers the strongest claim for invoking the loophole.

ProPublica’s database of IRS data includes the tax returns of thousands of wealthy business owners through 2018. These titans of capitalism, despite huge flows of ordinary income, often reported remarkably little self-employment income in the 2010s. The LP appears to have been their favored variety of partnership.

In 2017, Bill Ackman earned $413 million in income through an LP operated by the hedge fund he manages, Pershing Square, famous for taking activist stances in companies. As was typical in other years, Ackman reported self-employment income of $4.7 million, a small fraction of his total business earnings. The difference meant he paid $142,000 in self-employment tax instead of more than $13 million.

In a statement, a spokesperson said: “Mr. Ackman has followed the advice of his tax advisors whose interpretation of the law has been the industry standard since 1977. Should the law change, Mr. Ackman will of course adjust his tax payments accordingly.”

In 2018, at least $143 million flowed via a Blackstone LP to Stephen Schwarzman, the firm’s CEO. As in years past, he exempted the income from Medicare tax. Schwarzman, who sits atop an investment firm with over $1 trillion in assets, reported no self-employment income at all in five of the seven years between 2012 and 2018.

“Mr. Schwarzman is one of the largest individual taxpayers in the country and fully complies with all tax rules,” a spokesperson said.

Attacking Head-On

The IRS’ announcement of its audit campaign in 2018 meant the agency would stop pushing around the edges and unleash a frontal assault: Its audits would target not just the newer form of partnerships but also LPs.

This time, after years of audits and appeals within the IRS, the agency finally got its splashy court case. Many taxpayers chose to settle, but Cohen’s partnership and at least five others took their cases to tax court, the first in 2022. All argued they were following the law.

Soroban Capital, a hedge fund, was audited after converting to an LP from an LLC. Demonstrating the gulf between owners and employees, Soroban’s three partners collected $142 million in income over the two years of the audit, while paying a total of $74 million in salaries and wages (subject to Medicare tax) to the fund’s staff.

Soroban’s founder, Eric Mandelblatt, was once an employee. His compensation from Goldman Sachs cost him $128,000 in Medicare tax one year, according to ProPublica’s IRS database. After he started his own hedge fund and began earning tens of millions more, his Medicare tax bill never exceeded a third of that, the records show. Soroban did not respond to requests for comment.

In 2023, the IRS won a major tax court decision against Soroban. The “limited partner exception of I.R.C. § 1402(a)(13) does not apply to a partner who is limited in name only,” the court said, because Congress had only intended to “exclude earnings from a mere investment.” A “functional analysis,” the court said, was needed to determine whether a partner was really “limited.”

With the Soroban decision, the loophole entered a new stage in its history. It’s the most serious challenge since 1997 when, protected by Congress, the loophole emerged not only unscathed but stronger. This time, it’s up to the federal judges who will be reviewing appeals of the tax court’s rulings in the IRS’ cases.

One of the audit targets, Sirius Solutions, a consultancy, has already sought a more sympathetic venue than the U.S. Tax Court. Last summer, it turned to the 5th U.S. Circuit Court of Appeals, known for its conservative bent. Industry groups representing the hedge fund and real estate industry have filed amicus briefs. Tax law experts told ProPublica they are skeptical the IRS’ position will ultimately prevail.

Still, amid this uncertainty, the Treasury Department and IRS last year announced plans to start work on a regulation for Section 1402(a)(13). It’s a process that could take years if it isn’t halted by the incoming administration. If a new rule is finally released, it might again face a hostile Congress. It would also be subject to challenge in the courts.

As has always been the case, the simplest solution is for Congress to change the law. Democrats will keep trying, said a former senior congressional aide, especially when they propose some new expensive initiative and need ways to pay for it.

Including a fix for the Medicare tax loopholes is “a beautiful pay-for,” he said. “It’s real money, and there are not a lot of options sitting around that are this obvious and relatively straightforward technically.”

The last attempt came a couple years ago, when Democrats needed to cover the cost of their $2.4 trillion climate bill. Build Back Better, as it was initially called, passed the House with a provision similar to Furman’s gap-plugging tax. The proposal was estimated to raise $252 billion over 10 years.

But the bill stalled in the Senate, where Democrats needed every vote. In the summer of 2022, negotiations suddenly approached consensus on a new, slimmer bill, soon dubbed the Inflation Reduction Act. The gap-plugging tax was part of the mix.

As they had 25 years before, business groups quickly rallied. Several dozen trade groups co-signed a letter to congressional leaders. The National Federation of Independent Business launched radio ads. “Now Congress is considering a brand-new tax on West Virginia small businesses, an additional tax wrongly characterized as the closing of a loophole,” ran one ad targeting Sen. Joe Manchin, one of the two key swing votes.

When a deal was finally announced on the bill, the proposal was gone. There had been other, less politically dangerous options to raise revenue.

12/8/24

97% of Transgender Adolescents are Satisfied with and Continue Gender Affirming Medical Care

image manseok_Kim pixabay

A study published in AMA Pediatrics of 220 adolescents aged 12 years or older throughout Canada and the US has found high rates of satisfaction, with 97% of participants continuing to access gender-affirming medical care in the roughly 3 to 5 years since beginning treatment.

Only 4% of respondents—9 in total—indicated clear regret for at least 1 treatment. Of those, 4 have continued seeking gender-affirming care.

Most participants, who were 16 years old on average, indicated that the timing of treatment had been just right or expressed that they wished it had begun at an earlier age. Between 0% and 6% reported a desire that the treatment had commenced either later or never.

Although the results suggest high levels of satisfaction and low levels of regret with gender-affirming hormones and puberty blockers, the authors underscored the need to better understand cases of dissatisfaction, considering that regret was not synonymous with stopping care.

To access the study to determine "Levels of Satisfaction and Regret With Gender-Affirming Medical Care in Adolescence" Click Here

12/7/24

Tn. Senator defends ban on gender affirming care, days later pissed himself while being arrested

State Sen. Ken Yager, a co-sponsor of Tennessee SB1, the law now in front of the Supreme Court, defended the ban on gender-affirming care in an opinion piece. Days later Yager pissed himself while failing a sobriety test and was arrested for DWI, hit and run, and running a stop sign, according to WVLT News 8.

Yager's opinion appearing in the Tennessean "TN law bans trans children from gender-affirming care. SCOTUS must uphold that", is filled with imagery of protesters demanding an end to "child mutilation". In the article, he purports that his bill protects children too "immature" to make decisions and that he was virtually inundated with messages from constituents complaining of the harm youth gender-affirming care causes.

An opposing opinion published days later sets the record straight that legislators could not produce a single complaint, and trans people have been here since recorded history began. 

No, Senator Yager, it's immoral people like you who drink and drive and leave the scene of an accident without rendering aid who mutilate and kill.

Gender-affirming medical care saves lives.

12/6/24

Our bodies, their choice

Joseph Fons holding a Pride Flag, runs in front of the U.S. Supreme Court building after the Court issued a landmark 6-3 decision affirming that the prohibition on sex discrimination in Title VII of the Civil Rights Act of 1964 extends to discrimination based on sexual orientation and gender identity./photo Tom Brenner
The Supreme Court and the attack on trans kids: It was never about bathrooms, it was never about fountains. It is about our bodies, our choices, our lives.

"Our bodies, their choice" By Gabriel Haaland was originally published by 48Hills on 12/5/2024

On the heels of the worst anti-trans election campaign ever, in which the Trump campaign used transgender people to pit the voters against Kamala Harris, the conservative wing of the Supreme Court, three of whom were handpicked by Trump, is set to ignore the Equal Protection Clause of the US Constitution, and uphold a ban on gender-affirming health care for trans youth.

On Wednesday, Dec. 4, the Court heard oral arguments on Senate Bill 1, the Tennessee legislation that bans affirming care. This is the first time this issue has come before this court.

Over the last few years, the issue has been front and center, particularly in the South, and 25 other states have passed bans on gender affirming care. Out of the 300,000 high school-aged transgender youth, 118,000 live in the 26 states that have enacted bans, regardless of parental consent and medical recommendation.

Of the 26 states, 24 have banned puberty blockers and hormones, and these laws often threaten parents and medical providers even with imprisonment for medically treating transgender youth.

The playbook that these legislators, activists, and strategists are using to instigate cultural wars through anti-trans and gender-affirming bans are similar to those used to attack reproductive rights and a person’s right to choose. At heart, the right-wing groups, strategists and politicians do not want women to have the right to choose whether to have a baby and have control over their own body—and they certainly do not want a transgender person to exert control over their own body and their reproductive choices.

Bodily autonomy and reproductive choice are at the heart of the issue.

This point became crystal clear during oral arguments, when the attorney for Tennessee said that the state’s interests were harmed when a “girl” takes testosterone to “become a boy” because “she” becomes infertile.

Their takeaway? Our bodies, their choice.

Some have asked why it was important to give trans teenagers, their parents and their doctors the right to treat them before they are 18 with puberty blockers or sometimes hormones. The case for puberty blockers and hormones is dramatic. Recent studies have found that receipt of puberty blockers can dramatically reduce risk of suicidality—in some cases by more than 70 percent—among transgender youth, compared to those who were unable to access desired treatment.

Just to be clear, Trump has made all kinds of wild and untruthful allegations about young transgender people, but children do not medically transition. Children are not given hormones. They are accepted, loved, and cherished for who they are. There can be haircuts, changes in clothes, pronoun changes, but there are no hormonal treatments.

When they reach puberty, with a consultation with their doctor, a family and the youth may decide to use puberty blockers to give them more time to decide. But Trump has threatened to prosecute any doctor or parent who treats their child, and many states agree with him.

Moreover a recent study published in Nature Human Behavior confirms what many in the LGBTQ+ community have long feared: These anti-trans legislation efforts are directly linked to a staggering increase in suicide attempts among transgender and nonbinary youth. The Trevor Project’s research reveals suicide attempts among these young people surged by as much as 72 percent in states where harmful, discriminatory legislation was passed.

As for many in the trans community, this issue is very personal to me. I was a trans kid, and expressed to my parent that I was a boy when I was four years old. I drew picture stories of myself as a boy, mostly as a pirate with a dog.

When my parent realized that I considered myself a boy, she tore up my drawings and immediately began a long campaign of intense gender harassment. Her effort to convert me into a girl for the next ten years gathered in intensity until it became so violent at puberty that I ran away from home at the age of 14, never to return.

Like many, I know what it means for a trans youth to experience a hostile environment during their formative years, and even worse to endure the torture of not being able to transition. I am familiar with the impacts of these legislative decisions and why it matters that children are accepted and loved for what they are.

While most say it will be likely that the Court will uphold the ban on gender affirming care for trans youth, there was one very small glimmer of hope. During a line of questioning by Justice Amy Coney Barrett about de jure discrimination, she was surprised to learn of the cross-dressing laws and the military ban on transgender people, leaving some hopeful that she might play a pivotal role in the decision making on this case as she has done in the past.

There is no question that these efforts will also lead to attempts to bans on care for adults as well, like the right-wing attempts to take reproductive choice away from teenagers led to more extreme bans. In fact, during a line of questioning by Justice Sonia Sotomayor, she asked the attorney for Tennessee if given their logic, the state could block gender affirming laws for adults. He replied that the state could and that “democracy is the best check on potentially misguided laws.”

Justice Sotomayor flung back that “when you’re 1 percent of the population or less, [it’s] very hard to see how the democratic process is going to protect you.”

Trump also campaigned on bans for care for adults.

The implications of this case are far ranging, and while some may hope that the right-wing groups will be satisfied with winning on this issue, that belief is unjustified. They will be emboldened by this victory, and with each subsequent victory their aims will increase. We are fighting for our lives, and this is the first fight. It was never about bathrooms, it was never about fountains. It is about our bodies, our choices, our lives.

Gabriel Haaland is a former president of the Harvey Milk LGBTQ Democratic Club and a member of Queers 4 Voting Rights, a pro-democracy antiracist inclusive queer group in Asheville, NC.

12/5/24

Activists Arrested Protesting in Bathroom Near Speaker Johnson's Office

Protesters with Gender Liberation Movement, including Chelsea Manning (far right) and Racquel Willis (bottom left) sit inside the congressional bathroom closest to House Speaker Mike Johnson’s office on Capitol Hill, on December 5, 2024. (Orion Rummler for The 19th)

Transgender activists staged a sit-in on Thursday inside the women’s bathroom closest to House Speaker Mike Johnson’s office on Capitol Hill, to protest Republican-led efforts to keep transgender people from using restrooms that match their gender identity, 19th News reports.

The sit-in was organized by the Gender Liberation Movement. This volunteer-run grassroots group previously took to the streets of Washington, D.C. to protest Project 2025, a policy blueprint for a second Trump administration that would dramatically roll back LGBTQ+ rights.

“Democrats, grow a spine! Trans rights are on the line,” they chanted while seated inside the public restroom and outside of Johnson’s office. “Act up, fight back,” they said, echoing the well-known protest slogan of the AIDS activist group ACT UP.

The group is calling for elected officials to block Rep. Nancy Mace’s proposed bill that would ban trans people from bathrooms in museums, national parks and other federal property and for Democratic members of Congress to filibuster and block the bill if or when it comes to a vote.

As first reported by the 19th News.

Texas conservatives plan to further restrict trans lives this legislative session

People hold signs in front of the Texas Capitol during a protest for transgender kids' rights on March 1, 2022. Credit: Lauren Witte/The Texas Tribune

Emboldened by the recent election, some Texas lawmakers are already filing bills that would dictate bathroom use, limit gender identity markers on documents, and restrict funding for surgeries.

By Eleanor Klibanoff, The Texas Tribune

"Texas conservatives plan to further restrict trans lives this legislative session" was first published by The Texas Tribune, a nonprofit, nonpartisan media organization that informs Texans — and engages with them — about public policy, politics, government and statewide issues.

Sign up for The Brief, The Texas Tribune’s daily newsletter that keeps readers up to speed on the most essential Texas news.


Eight years ago, when conservative state lawmakers tried to restrict what bathrooms trans people could use, moderate Republicans quietly killed the bill in a special session.

Less than a decade later, that seems like a distant memory. The far-right now has the Legislature firmly in its grip and, emboldened by the recent election, they’re gearing up to make growing trans animus the social issue of the session.

[After Texas banned puberty blockers and hormones for trans kids, adults lost care, too]

Nationwide, Republicans have successfully pushed these laws as a way to protect children, by prohibiting them from medically transitioning before they turn 18 and stopping trans students from playing on sports teams that don’t align with their biological sex.

Texas has so far marched in lockstep with its conservative cousins in passing laws aimed at children. But some lawmakers want to further restrict the lives of trans adults as well, filing bills about bathroom use, gender identity markers on official documents and funding for gender reassignment surgery.

“The American people and especially Texans that I represent, they’ve had enough of it,” Rep. Brian Harrison, an arch-conservative from Midlothian, told The Texas Tribune. “They’re forcing you to celebrate something that’s at odds with objective reality, and in many instances, forcing tax dollars to fund it.”

The limit on how far Texas will go on this issue lies in the hands of conservative lawmakers, as the state is unlikely to face federal pushback as they did during the Biden administration. Incoming President Donald Trump has vowed to get Congress to pass a bill declaring there are only two genders, and to keep “transgender insanity the hell out of our schools.”

“I don’t see any reason the state would moderate its position at this point,” said Andrew Proctor, a political science professor at the University of Chicago who studies LGBTQ political issues. “If anything, the things they want to pursue will be easier now.”

A message is born

In 2016, the U.S. Supreme Court legalized same-sex marriage nationwide, and conservatives began casting around for a new social issue to back. They landed on the small but growing trans population, and the incremental discrimination protections they’d gained during the Obama administration.

The next year, in 2017, there were a few dozen anti-trans bills filed in state houses across the country. Many, like Texas' bathroom bill, failed. At that time, 57% of Republicans said society had gone “too far” in accepting trans people.

Then, they honed in on children. Terry Schilling, president of the American Principles Project, a right-wing political advocacy group, helped shape the messaging around this issue. He said conservatives are willing to be “polite” to people who identify as trans — to a point.

“Once you go into my daughter's athletics or in her locker room or showers, once you start giving kids gender transitions that mutilate them and sterilize them, then we're in a whole different world,” he told The Texas Tribune after the election.

All major medical associations acknowledge that gender dysphoria, the distress someone can feel when their physical presentation doesn’t match the gender they identify as, is a real medical condition best treated with gender-affirming care. That can range from social transition, in which someone goes by different pronouns or dresses differently, to medical treatments, including puberty blockers, hormone therapy and surgeries. Minors rarely undergo surgery to transition, and all decisions are made in consultation with their parents and medical professionals.

Nonetheless, the conservative messaging resonated. Last year, almost 80% of Republicans said society had gone too far in accepting trans people, and this year, even with Texas laying dormant, there were 669 anti-trans bills filed in state legislatures across the country.

But despite this sharp increase in anti-trans sentiment, it’s not entirely clear what Americans want their government to do about it. More than half of Republicans do not want to ban gender-affirming care for minors, and almost as many want to protect trans people from discrimination in jobs, housing and public spaces.

Texas’ ban on gender-affirming care for minors was widely condemned by medical associations, doctors, advocates and trans people, who called the laws “dangerous,” “cruel and grotesque,” and “devastating.” Every Republican, and a handful of Democrats, voted for the ban.

Now, trans people, advocates and health care providers are bracing for what comes next.

“It's almost necessary, based on their framework and the way they frame these cases, that they would argue that access to care for adults would be a violation in the same way as for children,” said Elana Redfield, the federal policy director at the Williams Institute, a research center on gender identity law and public policy at the University of California Los Angeles. “Texas has already made it pretty clear they intend to do that.”

The next frontier

In 2024, an off year for the Texas Legislature, other Republican states charged ahead, setting the agenda for what lawmakers might do when they reconvene in January. No state has fully banned adults from accessing gender-affirming care, but some, such as Florida, have significantly restricted the provision of these treatments, discouraging doctors and patients alike.

Texas lawmakers are already filing bills to tee up these issues. Sen. Bob Hall, a Republican from Edgewood, and Rep. Ellen Troxclair, an Austin Republican, have filed bills requiring government records to reflect that there are only two genders, tightly defining male and female based on reproductive organs. Other bills would prevent trans people from amending their birth certificates to reflect their gender identity.

These laws have the effect of “erasing transgender people altogether,” Redfield said. Some of this is already under way: Earlier this year, the Texas Department of Public Safety, under scrutiny from Attorney General Ken Paxton, began refusing to change the sex listed on someone’s driver’s license, even with a court order. The agency also began compiling names of people seeking the change.

Lawmakers are also hoping to resurrect the bathroom issue, as well as requiring trans people to be placed in jails or prisons based on the sex they were assigned at birth.

Harrison, the Midlothian Republican, has filed a bill that would forbid state funding to be used for transition-related care.

This idea gained traction during the presidential election, when Trump accused Vice President Kamala Harris of supporting taxpayer-funded gender reassignment surgery. In a small number of cases, federal inmates have won court battles that required the federal government to pay for their transition-related medical care.

Harrison said his focus is purely about how tax dollars are spent, and it’s the media who portrays these as social issues.

“We are making the lives harder for Texans of all stripes when we make them poorer, and we certainly shouldn’t make them poorer in the pursuit of leftist ideology,” he said.

Federal shifts

On Wednesday, the U.S. Supreme Court will hear arguments in a lawsuit challenging Tennessee’s gender-affirming care ban for minors, a case that could determine how far states like Texas can go with these restrictions. The U.S. Department of Justice sued in 2023, saying the law unconstitutionally discriminates on the basis of gender.

The suit was one of several attempts by the Biden administration to insulate trans people from the impacts of conservative state laws.

“The Biden administration has been the most explicitly protective administration for transgender people,” Redfield said. “We can anticipate the incoming president will claw back as much of that as possible.”

In his first term, Trump ejected trans people from the military and reversed many Obama-era discrimination protections. In his recent presidential campaign, he ran heavily on this record, culminating in an ad that said “Kamala is for they/them. President Trump is for you.”

Project 2025, the policy blueprint created by the conservative Heritage Foundation that many hope Trump will pull from, calls for removing “sexual orientation” and “gender identity” from all federal rules, regulations and legislation, and restricting gender-affirming care across age groups.

Trans people and advocates are preparing for what Congress and the White House might do, as well as where state legislatures might go without federal oversight to rein them in. Many groups are recommending trans people proactively change their government documents to align with their gender identity, where that’s still allowed; stock up on transition-related medications; and prepare to move states or leave the country, if needed.

Whatever Trump does on this issue, Texas is expected to go even further.

“Texas better do at least as good a job as Washington, D.C. is going to do on that front,” Harrison said. “And that’s what I’m committed to ensuring happens.”

This article originally appeared in The Texas Tribune at https://www.texastribune.org/2024/12/04/texas-transgender-restrictions-legislative-session/.

The Texas Tribune is a member-supported, nonpartisan newsroom informing and engaging Texans on state politics and policy. Learn more at texastribune.org.

12/4/24

Every American Medical Association Supports Youth Gender Affirming Medical Care

 Every major medical association and leading world health authority supports health care for transgender people and youth. They are also increasingly speaking out against the disinformation being spread by opponents of this care. Below are excerpts from 30+ organizations’ statements.

Reporters covering state bills and other discussions about this care should note that every major medical association supports health care for transgender people and youth as safe and lifesaving.

The following have issued statements in support of health care for transgender people and youth:

American Academy of Child and Adolescent Psychiatry

American Academy of Dermatology

American Academy of Pediatrics

American Academy of Physician Assistants

American Medical Association

American Nurses Association

American Association of Clinical Endocrinology

American Association of Geriatric Psychiatry

American College Health Association

American College of Nurse-Midwives

American College of Obstetricians and Gynecologists

American College of Physicians

American Counseling Association

American Heart Association

American Medical Student Association

American Psychiatric Association

American Society of Plastic Surgeons

American Society for Reproductive Medicine

American Urological Association

Endocrine Society

Federation of Pediatric Organizations

GLMA: Health Professionals Advancing LGBTQ Equality

The Journal of the American Medical Association

National Association of Nurse Practitioners in Women’s Health

National Association of Social Workers

Ohio Children’s Hospital

Pediatric Endocrine Society

Pediatrics (Journal of the American Academy of Pediatrics ) and Seattle Children’s Hospital

Texas Medical Association

Texas Pediatric Society

United States Professional Association for Transgender Health (USPATH)

World Health Organization (WHO)

World Medical Association

World Professional Association for Transgender Health

In the December 23 issue of the journal Pediatrics, doctors from Seattle Children’s Hospital published an article that describes bans on care for transgender youth as a form of child abuse.

In “Prohibition of Gender-Affirming Care as a Form of Child Maltreatment: Reframing the Discussion,” the authors write: “These legislative efforts operate under the guise of protecting children. In reality, they punish caregivers and physicians when they choose to support children. They deny children access to routine health care that has been shown to decrease dramatically high rates of suicide and depression for TGD (transgender and gender diverse) youth.  They fuel discriminatory rhetoric, which negatively impacts the mental health of TGD children and imperils their safety.”

Ohio Children’s Hospital submitted testimony to the Ohio state Senate in December 2023 in defense of transgender health care for youth and against Ohio’s HB68, which sought to ban it:

“It is so unfathomable to hear the statements made regarding what pediatric providers do and don’t do when treating youth who are expressing a conflict between the sex they were assigned at birth and the gender with which they identify. This false narrative is intended to incite fear in order to take away parental rights and restrict health care,” wrote Associate Chief Medical Officer for Behavioral Health at Ohio Children’s Hospital-Dayton, Kelly Blankenship.

“At Dayton Children’s Hospital, all service lines within our hospital follow national standards of care to ensure quality, safety, and deliver best outcomes,” Blankenship continued. “All care delivered is age-appropriate, and aligned with clinical practice guidelines based on research… Our health care providers evaluate all symptoms, and patients are screened and evaluated for all comorbid mental health conditions before determining if treatment is needed. We seek to ensure that the decision of each parent is informed by medically sound information and is free from coercion or undue influence. Again, Dayton Children’s does not perform hysterectomies, or any genital surgeries, as part of gender affirming medical care. The care provided by the medical and mental health professionals at Dayton Children’s is all evidence-based. We believe all young people should have access to comprehensive, developmentally appropriate, mental health care and gender-affirming health care provided in a safe and inclusive environment. Transgender children, adolescents, and their families deserve care that is grounded in science, compassion and ethics.”

Nick Lashutka, President and CEO of the Ohio Children’s Hospital, submitted additional testimony in May 2023: “The allegations made against children’s hospitals by supporters of HB 68 are deeply offensive and disappointing. Children’s hospitals across Ohio are filled with pediatric experts who have dedicated their lives to caring for kids.”

“Here are the facts.” Lashutka continued, “1. Children’s hospitals in Ohio have responded to a need in the community to serve a very small, but complex population. 2. All medical gender dysphoria treatment requires parental consent. It is supported by a multi-disciplinary team of professionals, including pediatric specialists in psychiatry, adolescent medicine, and endocrinology. 3. Again, we DO NOT perform surgeries on minors for the condition of gender dysphoria. 4. Individuals diagnosed with gender dysphoria are consistent, persistent, and insistent for a lengthy period of time. The notion that kids declare a feeling and are immediately medicated at one of our clinics is false. 5. Patients do not self-diagnose their gender dysphoria; they present with symptoms of gender dysphoria. Their health care providers evaluate these symptoms, and only their health care providers make diagnoses. 6. All comorbid mental health conditions are screened and evaluated before determining if additional treatment is needed. 7. Patients do not receive blockers or hormones at their first appointment.”

On June 12, 2023, The American Medical Association passed a resolution drafted by The Endocrine Society to protect access to evidence-based care for transgender and gender-diverse youth, noting “it is the responsibility of the medical community to speak out in support of evidence-based care. Medical decisions should be made by patients, their relatives and health care providers, not politicians.”

The resolution was cosponsored by:

  • The American Academy of Pediatrics
  • The American College of Obstetricians and Gynecologists
  • The American Urological Association
  • The American Society for Reproductive Medicine
  • The American College of Physicians
  • The American Association of Clinical Endocrinology
  • GLMA: Health Professionals Advancing LGBTQ+ Equality
  • the AMA’s Medical Student Section

The resolution stated the widespread misinformation and bans on care “do not reflect the research landscape. More than 2,000 scientific studies have examined aspects of gender-affirming care since 1975, including more than 260 studies cited in the Endocrine Society’s Clinical Practice Guideline.”

Additional excerpts from organization statements:

American Academy of Child and Adolescent Psychiatry: “The AAP’s 2018 policy statement ‘Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents’ defines gender affirmation as developmentally appropriate, nonjudgmental, supportive care provided in a safe clinical space. The policy states that pediatric providers, often the first medical professionals to discover a child’s gender identity concerns, have a special role in caring for these patients who have a high risk of depression, anxiety and suicide. The care model is not one-size-fits-all, said Brittany Allen, M.D., FAAP, a member of the AAP Section on LGBTQ Executive Committee. It recognizes the wide spectrum of normal, healthy gender identities.” (January 6, 2022)

American Academy of Child and Adolescent Psychiatry: “(AACAP) supports the use of current evidence-based clinical care with minors. AACAP strongly opposes any efforts – legal, legislative, and otherwise – to block access to these recognized interventions. Blocking access to timely care has been shown to increase youths’ risk for suicidal ideation and other negative mental health outcomes. Consistent with AACAP’s policy against conversion therapy, AACAP recommends that youth and their families formulate an individualized treatment plan with their clinician that addresses the youth’s unique mental health needs under the premise that all gender identities and expressions are not inherently pathological.” (November 8, 2019)

American Academy of Dermatology: “The AADA recognizes the dignity and identity of transgender individuals and advocates for dermatologists’ ability to provide therapy and procedures that help the mental and physical well-being of these and all patients. Transgender and gender-diverse individuals can benefit greatly from medical and surgical gender-affirming treatments. These treatments are often medically necessary for the health and well-being of these patients and are not to be considered as cosmetic or elective. Decisions about care should remain within the confines of the physician-patient relationship, guided by strong medical evidence and the best interests of the individual patient.” (June 1, 2021)

American Medical Association: “Empirical evidence has demonstrated that trans and non-binary gender identities are normal variations of human identity and expression. For gender diverse individuals, standards of care and accepted medically necessary services that affirm gender or treat gender dysphoria may include mental health counseling, non-medical social transition, gender-affirming hormone therapy, and/or gender-affirming surgeries. Clinical guidelines established by professional medical organizations for the care of minors promote these supportive interventions based on the current evidence and that enable young people to explore and live the gender that they choose. Every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people.” (April 26, 2021)

The American Medical Association passed a resolution drafted by The Endocrine Society to protect access to evidence-based gender-affirming care for transgender and gender-diverse youth. (June 12, 2023)

American Nurses Association: “The American Nurses Association strongly opposes any legislation or policy action that places restrictions on transgender health care and that criminalizes gender-affirming care. Due to recent state legislative efforts, transgender and gender-diverse youth and their parents or guardians who choose to access gender-affirming care may come under legal assault in many states.  Health care professionals, including nurses and advanced practice registered nurses (APRNs) who provide gender-affirming care, may also be subject to judicial process or other legal action. These restrictive laws interfere with the trust and confidentiality between patients, parents or guardians, and clinicians in the delivery of evidence-based care. The legislative intent and medical claims behind these laws are not grounded in reputable science and conflict with the nurse’s obligation to promote, advocate, and protect the rights, health, and safety of patients. ANA’s Position Statement Nursing Advocacy for LGBTQ+ Populations (2018) underlines the mandate that nurses “must deliver culturally congruent care and advocate for lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) populations.” (October 26, 2022)

American Academy of Pediatrics“There is strong consensus among the most prominent medical organizations worldwide that evidence-based, gender-affirming care for transgender children and adolescents is medically necessary and appropriate. It can even be lifesaving. The decision of whether and when to start gender-affirming treatment, which does not necessarily lead to hormone therapy or surgery, is personal and involves careful consideration by each patient and their family.” (August 10, 2022)

American Academy of Pediatrics: “The American Academy of Pediatrics recommends that youth who identify as transgender have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space. We also recommend that playing on sports teams helps youth develop self-esteem, correlates positively with overall mental health, and appears to have a protective effect against suicide. These bills not only ignore these recommendations, they undermine them.” (March 16, 2021)

American Academy of Physician Assistants“All the undersigned associations have adopted policies or otherwise support addressing the specific health concerns of LGBTQ people, including opposition to discrimination in health care and insurance coverage based on an individual’s sexual orientation or gender identity. As part of that commitment, our organizations support public and private health insurance coverage for the treatment of gender dysphoria when medically necessary.” (Signatories: American Academy of Nursing, American Academy of PAs, American Academy of Pediatrics, American Academy of Psychiatry and The Law American Association for Geriatric Psychiatry, American College Health Association, American College of Physicians, American Medical Association, American Medical Student Association, American Medical Women’s Association, American Nurses Association, American Pediatric Surgical Association)  (May 24, 2019)

American Association of Clinical Endocrinology: “Transgender and gender diverse people represent a sizable and growing segment of the U.S. and world Population. It is estimated that over 1 million people in the U.S. alone are transgender or gender diverse. Many transgender and gender diverse people seek hormone therapy under the supervision of an endocrinologist or other medically trained health care professional to better align their bodies with their gender identities. Being transgender is widely accepted to require medical treatment for those patients who seek it.  Medical treatment may include behavioral assessment, hormone therapy, and surgery. These treatments are well established in the relevant established, international professional society guidelines including those from the Endocrine Society co-sponsored by the American Association of Clinical Endocrinology (AACE) and the World Professional Association for Transgender Health (WPATH).” (March 7, 2022)

American Association of Geriatric Psychiatry: “With the overarching goals of improving the healthcare of older transgender individuals and of inspiring pertinent clinical research, a session at the 2017 American Association for Geriatric Psychiatry Annual Meeting focused on an interdisciplinary approach to transgender aging. The older the transgender adult, the more likely the individual grew up in a historical context when there was greater social stigma towards their gender identity, even among mental health professionals… In spite of notable health disparities, some evidence points to resilience among transgender older adults. The mental health professional often serves as the first contact for a patient who is struggling with gender identity.” (February 7, 2018)

American College Health Association: “As a society, we have made significant strides in removing barriers and improving health care and outcomes for transgender and gender diverse patients. Individuals feel more comfortable disclosing their authentic gender and are doing so at younger ages. Health care services should be made universal to all and should not discriminate in any way, whether this be on age; race/ethnicity, sex; sexual orientation; gender (including gender identity); marital status; physical size; religious, spiritual or cultural identity; psychological/physical/learning disability; socioeconomic status; or veteran status. This is consistent with the long-held values of cultural inclusion, respect, equality, and equity that ACHA has advocated for. Therefore, ACHA opposes any legislation, both state or federal, that would restrict or limit access to gender-related medically necessary services for transgender youth and adults.” (February 8, 2023)

American College of Nurse-MidwivesThe American College of Nurse-Midwives (ACNM) supports efforts to provide transgender and gender non-binary (TGNB) people with access to safe, comprehensive, culturally-responsive, and respectful health care. ACNM is committed to taking the following actions:  Incorporating gender-inclusive language into ACNM documents. Offering educational opportunities to members of the midwifery community on how to care for TGNB people. Advancing legislation and policies that prohibit discrimination based on gender expression and/or identity. Supporting measures to ensure TGNB people have comprehensive and unrestricted access to health insurance coverage. (March 2021)

American College of Obstetricians and Gynecologists: “The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity, urges public and private health insurance plans to cover necessary services for individuals with gender dysphoria, and advocates for inclusive, thoughtful, and affirming care for transgender individuals.” (January 2017)

American College of Physicians“A growing number of states are banning gender-affirming health care and pursuing anti-LGBTQ+ legislation, contrary to ACP policy, which urges non-discrimination in health care.  ACP opposes these restrictions on health care for transgender individuals, who already may face extreme barriers to accessing care, and strongly objects to any unnecessary government interference with any health care services.” (April 24, 2023)

American Counseling Association“The American Counseling Association (ACA) is committed to nondiscrimination and prevention of harassment in all forms (verbal, physical, sexual, emotional, and psychological), including protections for all diverse groups including protections for transgender and nonbinary individuals. ACA recognizes the stress and psychological impact of discrimination and is committed to helping counselors advocate for nondiscrimination policies and practices in their schools, colleges/universities, clinical mental health settings, communities, and in the nation.” (March 29, 2019)

American Heart AssociationThe AHA opposed the repeal of transgender-specific protections under Section 1557 of the Affordable Care Act noting: “Transgender people also face a high degree of insurance discrimination. Historically, many plans have used transgender-specific exclusions to deny transgender people coverage for medically necessary care—including hormone therapy, mental health counseling, and surgeries—even though the same services are routinely covered for non-transgender individuals… These experiences of healthcare and health insurance discrimination contribute to significant health disparities.” (September 2019)

American Medical Student Association: “AMSA adamantly opposes treatment policies that discriminate against patients based on their sexual orientation and gender identity, or that inhibit their access to quality care. Health care for transgender people should be individualized, holistic, and comprehensive – including, but not limited to surgical treatment– and transgender persons in the military should be allowed to openly undergo gender transition and be eligible for the equitable benefits and rights afforded to cisgender service personnel, including health care.” (August 2017)

American Medical Women’s AssociationThe American Medical Women’s Association (AMWA) supports the US Department of Health and Human Services adopting revisions to Section 1557 of the Affordable Care Act that codify protections for LGBTQ+ people from mistreatment by physicians, other clinicians, and insurers. Adopting this rule will restore and strengthen protections for LGBTQ+ people by clarifying that the definition of “sex” discrimination applies to discrimination based on sex characteristics, intersex traits, and pregnancy and pregnancy termination, and aligns with federal court decisions prohibiting discrimination based on gender identity and sexual orientation.  AMWA urges adoption of these crucial protections.

American Psychiatric Association: “Our organizations, which represent nearly 600,000 physicians and medical students, oppose any laws and regulations that discriminate against transgender and gender-diverse individuals or interfere in the confidential relationship between a patient and their physician. That confidentiality is critical to allow patients to trust physicians to properly counsel, diagnose and treat. Our organizations are strongly opposed to any legislation or regulation that would interfere with the provision of evidence-based patient care for any patient, affirming our commitment to patient safety. We recognize health as a basic human right for every person, regardless of gender identity or sexual orientation.” (Joint statement with the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Obstetricians and Gynecologists, American Osteopathic Association; April 2, 2021)

American Society of Plastic Surgeons“The delivery of gender affirming care is not a political issue, but rather a health care issue – Gender dysphoria is a medical diagnosis, not a political choice. ASPS firmly believes that plastic surgery services can help gender dysphoria patients align their bodies with whom they know themselves to be and improve their overall mental health and well-being. The Society will continue its efforts to advocate for full access to medically necessary transition care and stand up to those who oppose it – from the board rooms of big tech to Capitol Hill.” (June 22, 2021)

American Urological Association: “The AUA is committed to the principle that medical decision-making for transgender children is the responsibility of parents acting in their child’s best interest to ensure their physical and mental health, safety and well-being, and that consultation with medical professionals and education via medically safe (respected, peer-reviewed) resources must not be legislated or criminalized.”

Federation of Pediatric Organizations: “We stand with pediatricians who partner with families every day to make the best possible decision for each individual child based on available research and evidence pertinent to that child’s care. Transgender and gender-diverse children and youth deserve to lead safe, healthy lives in environments that allow them to be their authentic selves. That can only happen if physicians are allowed to treat these children in the same manner, and with the same respect, that we expect them to treat every other child. Our mission to advance child health will succeed only if we work to improve health outcomes for all children.” (March 28, 2022)

GLMA: Health Professionals Advancing LGBTQ EqualityMany but not all transgender people experience gender dysphoria, a medical condition defined by the American Psychiatric Association as a “conflict between a person’s physical or assigned gender and the gender with which he/she/they identify.” Standards of care and accepted medically necessary services that affirm gender or treat gender dysphoria may include but are not limited to mental health counseling, non-medical social transition, gender-affirming hormone therapy, and/or gender-affirming surgeries. Every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people and has called for health insurance coverage for treatment of gender dysphoria.” (March 2019)

The Journal of the American Medical Association: “Transgender and gender diverse patients should receive nonjudgmental care from appropriately trained health care professionals. Gender-affirming primary care includes preventive care, mental health and substance use disorder screening, hormone therapy, and education about nonmedical/nonsurgical gender-affirming interventions. (September 15, 2022)

National Association of Nurse Practitioners in Women’s Health: “The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms each individual’s right to quality, evidence-based sexual and reproductive healthcare and celebrates diversity of sexuality, gender identity, and gender expression. NPWH is committed to providing quality sexual and reproductive healthcare to all individuals, regardless of gender identity or expression… Transgender and Gender Diverse individuals have a right to care that aligns with and affirms their gender identity.” (May 2022)

National Association of Social WorkersGender-Affirming Health Care Saves Lives: “The National Association of Social Workers (NASW) asserts that discrimination and prejudice directed against any individuals on the basis of gender identity or expression are damaging to the social, emotional, psychological, physical and economic well-being of transgender and gender diverse (TGD) people and society as a whole. The unprecedented increase in legislation focused on TGD youth seeking affirming health care, the professionals who provide their medical care, and the families and social supports that offer resources to them is an unfortunate indicator of the lack of understanding and misinformation that currently exists… NASW will work to repeal discriminatory legislation and regulations that do not honor someone’s self-identified gender identity, transgender-inclusive health care access, health insurance options, or use of language promoting health equity and inclusive communication.”

Pediatric Endocrine Society: “Bills that threaten the health of transgender and gender diverse (TGD) youth have been introduced in multiple state legislatures across the United States. These bills undermine medical recommendations and seek to criminalize health care professionals who provide gender-affirming care such as puberty suppressing medications and gender-affirming hormone therapy. We caution legislators and the public that the support and implementation of these bills will worsen mental health, increase the risk of suicide, and contribute to poorer overall health in our TGD patients. Such bills contradict evidence-based Standards of Care recommendations from the Pediatric Endocrine Society as well as Position Statements from several national and international medical associations with expertise in the care of TGD youth, such as the American Academy of Pediatrics, the Endocrine Society, the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association and the World Professional Association for Transgender Health. The Pediatric Endocrine Society recommends an affirmative model of care that supports one’s gender identity, and follows a multidisciplinary approach that includes involvement of mental health professionals, patients and their families. Puberty suppression and/or gender-affirming hormone therapy is recommended within this evidence-based approach on a case-by-case basis as medically necessary and is potentially lifesaving. The implementation of these recommendations has been demonstrated to improve the psychological health and well-being of TGD youth.” (April 2021)

Texas Medical Association: “filed friend-of-the-court brief in the case in support of medically necessary, gender-affirming care, and opposing the criminalization of such treatment… TMA’s brief addresses “the acceptance and medical necessity of gender-affirming care for adolescents with gender dysphoria” and raises concerns the state actions “will create barriers in access to care for transgender adolescents, a vulnerable population that already faces barriers in access to care. The full range of evidence and the current recommendations developed by the American Academy of Pediatrics, and affirmed by every major American medical association, supports the medical necessity and appropriateness of providing gender-affirming support and care to transgender youth and adolescents. Medical care for transgender youth and adolescents is evidence-based and has proven effectiveness.” (March 10, 2022)

Texas Pediatric SocietyStatement opposing Actions in Texas Threatening Health of Transgender Youth: TPS has long-advocated against prohibitions on gender-affirming care in Texas. For young people who identify as transgender, studies show that gender-affirming care can reduce emotional distress, improve their sense of well-being and reduce the risk of suicide. “Evidence-based medical care for transgender and gender diverse children is a complex issue that pediatricians are uniquely qualified to provide. This directive undermines the physician-patient-family relationship and will cause undue harm to children in Texas. TPS opposes the criminalization of evidence-based, gender-affirming care for transgender youth and adolescents. We urge the prioritization of the health and well-being of all youth, including transgender youth.”

United States Professional Association for Transgender Health (USPATH): “USPATH and the World Professional Association for Transgender Health (WPATH) denounces the emergency regulation halting gender-affirming healthcare for transgender and gender diverse (TGD) children and adolescents issued by Missouri Attorney General Andrew Bailey as lacking scientific grounding. The WPATH Standards of Care for the Health of Transgender and Gender Diverse People, now in its 8th version (SOC8), is the foremost evidence-based guideline for the provision of TGD healthcare. SOC8 is based on the best available science with input from over 100 global medical professionals and experts and represents best-practice guidelines for the provision of gender-affirming healthcare. Gender-affirming interventions are based on decades of clinical experience and research and are not considered experimental. Gender affirming hormone therapy (GAHT) is a component of widely accepted medically necessary care for TGD people.” (March 22, 2023)

World Health Organization (WHO): “WHO’s role, to promote health for all, means it is committed to inclusive healthcare and equitable access for trans, gender diverse and all other people… Our fight is for #HealthForAll” (28), demonstrating WHO’s highest level commitment to support countries to attend to the health needs of transgender and gender diverse people.”

World Medical Association: “The WMA emphasizes that everyone has the right to determine one’s own gender and recognizes the diversity of possibilities in this respect. The WMA calls for physicians to uphold each individual’s right to self-identification with regard to gender. The WMA asserts that gender incongruence is not in itself a mental disorder; however, it can lead to discomfort or distress, which is referred to as gender dysphoria (DSM-5). The WMA affirms that, in general, any health-related procedure or treatment related to an individual’s transgender status, e.g. surgical interventions, hormone therapy or psychotherapy, requires the freely given informed and explicit consent of the patient. The WMA urges that every effort be made to make individualized, multi-professional, interdisciplinary and affordable transgender healthcare (including speech therapy, hormonal treatment, surgical interventions and mental healthcare) available to all people who experience gender incongruence in order to reduce or to prevent pronounced gender dysphoria.” (October 2015)

World Professional Association for Transgender Health“Both the World Professional Association for Transgender Health (WPATH) and the US affiliate, the United States Professional Association for Transgender Health (USPATH), vehemently oppose the broad and sweeping legislation being introduced and ratified in states across the country to ban access to gender-affirming health care to transgender and gender diverse (TGD) people. WPATH’s long-standing Standards of Care for Transgender and Gender Diverse People, now in its eighth version (SOC8), explain in detail the science- and evidence-based benefits of gender affirming care for TGD people. Any legislation that restricts or prohibits access to this care is against best practice medical standards and is condemned by WPATH and USPATH.”  (March 8, 2023)