New GAC Guidance Leads Some to Ask: What Do We Do Now?

Medscape

2 days ago

Clinicians and hospitals are struggling to navigate care for young patients with gender dysphoria following new federal guidance released earlier this year that favors psychotherapy and attempts to block recommended medical and surgical gender-affirming care (GAC) treatments.
The Trump administration escalated efforts to bar GAC earlier this month when the Department of Justice (DOJ) issued more than 20 subpoenas to clinics and providers that offer the treatments to pediatric patients. The subpoenas came on the heels of a day-long workshop by the Federal Trade Commission, which is claiming the medical treatments may constitute unfair or deceptive trade practices.
'There has been steady ongoing pressure from this administration, trying to force providers to abandon standard of care treatments for adolescent gender dysphoria,' said Jack Turban, MD, a San Francisco pediatric psychiatrist and author of the book, Free to Be: Understanding Kids & Gender Identity told Medscape Medical News. 'Every major medical organization opposes these efforts. Nonetheless, the efforts have been successful in scaring physicians and pushing some hospitals to close their clinics and abandon their patients.'
In the wake of directives against GAC, some hospitals are shuttering clinics that provided transgender care, physicians are being forced to provide information about their GAC practices, and patients and families are faced with confusion and concern about what to do next.
At the same time, clinicians who provide GAC are facing threats from the public and confronting contrasting legal obligations about best treatment practices. Adding to the confusion, 16 states filed a lawsuit this week against the Trump administration, arguing that its actions amount to an illegal nationwide ban of GAC in minors.
This rapidly changing and uncertain landscape has left many to ask: What do we do now?
Escalation in Efforts: A Timeline
The move to curb GAC treatment in pediatric patients began in January with an executive order signed by President Donald Trump that prohibits physicians from providing GAC to youth and threatens to withhold federal funding from hospitals that offer such care.
Specifically, the order denounces the use of 'chemical and surgical mutilation,' which it defines as the use of puberty blockers, sex hormones, and any surgical procedure that attempts to alter or remove an individual's sexual organs to minimize or 'destroy their natural biological functions.'
Family, medical providers, and organizations that serve transgender patients sued over the order and a federal judge issued a nationwide preliminary injunction blocking its enforcement.
The Trump administration appealed the injunction, which is pending before the Fourth Circuit. The injunction is still in-effect, although plaintiffs claim the administration is violating the judge's injunction by sending notices to providers and continuing to make threats over the use of GAC.
In April, US Attorney General Pam Bondi instructed US attorneys to investigate and prosecute health centers for treating adolescents with GAC, suggesting that providing certain types of treatment may run afoul of several federal laws.
A report on the use of GAC to treat gender dysphoria in pediatric patients issued in May by the Department of Health and Human Services (HHS) departed from accepted guidelines from most physician associations, suggesting that psychotherapeutic approaches are optimal.
The Trump administration later sent letters threatening action if providers fail to follow the HHS guidance.
A number of hospitals across the US received a letter in May from the Centers for Medicare and Medicaid Services, requesting information about their GAC practices, including billing information, provider financials, and information on informed consent practices for pediatric patients.
The latest escalation came on July 9 when the US DOJ sent more than 20 subpoenas to doctors and clinics involved in performing transgender medical procedures on children. The department's investigations include healthcare fraud, false statements, and other allegations, according to a DOJ statement.
Also in July, the Federal Trade Commission (FTC) held a workshop on the 'unfair or deceptive trade practices' of GAC. During the workshop, FTC officials said it would be a new priority for the agency to use its authority to combat 'unfair or deceptive practices related' to GAC.
FTC Commissioner Melissa Holyoak stated it's the FTC's role to 'protect children from deceptive statements regarding such treatments' and that the agency has a strong history of enforcement actions against unfair and deceptive healthcare-related claims.
In August, 16 states and the District of Columbia filed a federal lawsuit against the administration, arguing its actions against clinicians and medical facilities amount to a nationwide ban on GAC for people younger than 19 years. Such actions are illegal, the states argue, because there is no federal law banning GAC in minors.
Caught in the Middle
The federal directives and subsequent lawsuits have led to an increase in queries from confused and worried patients and parents, said a Tennessee pediatrician and member of the Tennessee Chapter of the American Academy of Pediatrics (AAP) who asked to remain anonymous due to concerns about his personal safety.
In Tennessee, physicians have been restricted from prescribing hormone therapy or puberty blockers to patients younger than 18 years for the purpose of treating gender dysphoria since the state's 2023 ban.
In June 2025, the US Supreme Court upheld the Tennessee ban, effectively clearing the way for other states to restrict or ban GAC. To date, more than 25 have enacted bans or policies that limit youth access to the treatments.
Since Tennessee's ban, physicians have been referring young patients seeking treatment with puberty blockers or hormone therapy to other states for care, the Tennessee pediatrician said. Some outside clinics have now closed or are turning away patients. In some cases, the patients have been started on hormone replacement at the out-of-state clinics, he said.
'They're left up in the air and [wondering], 'Well, what do we do now?'' he said. 'There's not anything that we can do to directly help them.'
As providers attempt to navigate an increasingly politicized medical landscape, they find themselves caught in the middle between patients seeking treatment and an acute awareness that how they respond could harm their entire health systems, Meredithe McNamara, MD, a pediatrician and assistant professor at Yale School of Medicine and co-director of the Integrity Project at the Yale Law School, New Haven, Connecticut, told Medscape Medical News . McNamara practices GAC, primarily for patients 18 years or older.
'If an institution shuts down their gender services in anticipation of brutal political backlash, they're going to see an uptick in mental health emergencies in their psych units and their ICUs,' McNamara said.
Whether the administration will take action against clinicians and hospitals that continue to follow GAC guidance from the American Medical Association (AMA) and the AAP is unclear, McNamara said.
'I don't think anybody knows right now,' McNamara said. 'All of these threats, it's saber-rattling, it's rhetoric.'
Wave of Clinic Closures
Based on the recent closure of clinics and the halting of GAC-related treatment at some hospitals, the pressure from the Trump administration appears to be working, Jack Drescher, MD, a psychiatrist and psychoanalyst in private practice in New York City and a past president of the New York County Psychiatric Society, told Medscape Medical News .
Earlier this year, Denver Health in Colorado stopped providing gender-affirming surgeries for those younger than 19 years and Children's National Hospital in Washington, DC, paused prescriptions of puberty blockers and hormone therapy. Hospitals in Illinois, Virginia, New York, and a number of other states have followed suit, even in cases where state laws allow GAC treatments in minors.
In June, Stanford Medicine became the latest center to pause certain GAC services for patients younger than 19 years. Stanford Medicine said in a statement that it paused the surgeries after careful review of the latest actions and directives from the Trump administration and consultation with clinic leadership.
'We took this step to protect both our providers and patients,' Stanford Medicine said in the statement. 'This was not a decision we made lightly, especially knowing how deeply this impacts the individuals and families who depend on our essential care and support. Even as circumstances change, we remain committed to providing high quality, thorough and compassionate medical services for every member of our community.'
One of the nation's oldest and largest trans youth centers, the Center for Transyouth Health and Development at Children's Hospital Los Angeles in Los Angeles closed its doors in July. The center's Medical Director, Johanna Olson-Kennedy, MD, declined a request to speak about the closure.
In a statement, the center acknowledged the upcoming closure and said the staff was 'heartbroken to learn of the decision from hospital leaders, who emphasized that it was not made lightly but followed a thorough legal and financial assessment of the increasingly severe impacts of recent administrative actions and proposed policies.'
'Not Based on Science'
Many families have left states with GAC-related bans because their children can no longer get care, Drescher said, adding that in some areas, parents are being accused of abusing their children for providing them with GAC.
'We're seeing something similar to what happened with attitudes toward abortion, which is that there are parts of the country where you can no longer access care,' Drescher said.
The landscape is also becoming more worrisome for physicians who provide GAC, he added. In another parallel to threats made against clinicians who perform abortions, the names of hospitals and providers who provide GAC have been shared publicly on social media online.
Drescher referenced one specific website that hosts such a list and provides data on the top providers that have billed for gender-related surgical procedures for minors.
The names of physicians who practice GAC are included in some of the content, according to a review by Medscape Medical News.
Medical Groups Respond
Medical associations widely condemned the HHS report and other actions by the Trump administration to clamp down on GAC. The AAP questioned the credibility of the report, saying the report 'misrepresents the current medical consensus and fails to reflect the realities of pediatric care.'
Similarly, a joint statement from the American Psychiatric Association and other leading medical associations said physicians should not be criminalized or penalized for 'providing care and that medical standards of care and physician training and education must remain evidence-based and free from political interference.'
The AMA and other associations have long recommended a staged process for transgender minors that allow youth to explore and live the gender they identify with, while keeping other options open.
According to the AMA, evidence has consistently shown that providing GAC that is age-appropriate and evidence-based, leads to improved mental health outcomes. Denying such care on the other hand, has been linked to a higher incidence of anxiety, depression, and self-harm in young people, the AMA stated.
'Gender-affirming care seeks to minimize the distress trans individuals experience by providing a supportive, nonjudgmental environment that acknowledges the individual's gender identity, or uncertainty about their gender identity,' former AMA President Jack Resneck Jr, wrote in a recent AMA article.
'This type of care also offers interventions to reduce the incongruence between gender identity and the individual's sex assigned at birth and gives patients who struggle with their gender identity the time and support they need to resolve that struggle,' he added.
Legal, Ethical Questions Raised
However, an executive order cannot change state law or federal regulations, said Craig Konnoth, a professor at the University of Virginia School of Law, Charlottesville, Virginia. Konnoth wrote in a June article about the legal and ethical impacts of the administration's executive order in Health Affairs .
'It basically has no force,' Konnoth told Medscape Medical News . 'It says to agencies, 'please change the law,' but does not change the law itself. The executive order isn't a good reason for organizations to stop providing care, and in fact, in many jurisdictions, organizations are required under the law to keep providing care.'
In his Health Affairs piece, Konnoth called the criminal actions threatened by the administration, such as violating female genital mutilation protections and running afoul of the Food, Drug, and Cosmetic Act, 'far-fetched.' He noted that pediatric procedures rarely involve genital surgery, and that state protections already prohibit fraud and misrepresentation in medical care.
Even the funding withdrawal warnings lack immediate legal effect, he said. To change the conditions of a hospital's participation in Medicare and Medicaid would mean a rulemaking process that would likely take more than a year.
The flip side is that hospitals and physicians could land in legal or ethical trouble for ending GAC, according to Konnoth. A number of states prohibit discrimination based on gender identity. In addition, state laws generally prohibit abrupt cessation of care, he said. Patients can sue physicians over a sudden withdrawal of care without sufficient notice and time to find alternative treatment.
'Physicians, I will fully admit, are caught in a difficult spot because you've got conflicting threats you are facing,' he said. 'But the fact remains that the law in many jurisdictions requires physicians to keep providing care.'
McNamara said the differing laws and obligations make practicing medicine extremely challenging for physicians right now.
'You don't provide care, or you do provide care, and the negative consequences are devastating on either side,' she said. 'What we're dealing with is the question of: What force is the most influential and powerful right now? These are things the medical profession was never supposed to deal with.'