How gender-affirming care is becoming a political test for top medical groups

Orion Rummler

This story was originally reported by Orion Rummler of The 19th. Meet Orion and read more of their reporting on gender, politics and policy.

The largest medical association in the United States supports gender-affirming care — a stance it has reiterated in different ways over the last 10 years. But as Republicans press leading medical organizations on health care for transgender youth, the American Medical Association (AMA) is the latest group caught between political rhetoric and the complex realities of specialized care that few people receive.  

As patients, families and doctors navigate this care in an increasingly confusing and hostile landscape, what medical groups say matters. But lately, what they’ve had to say — and how politicians interpret it — has only caused more uncertainty. 

The AMA’s stance was already in question after a January meeting between leaders of major medical groups and Dr. Mehmet Oz, the head of the Centers for Medicare and Medicaid Services. After that meeting, which was first reported by The New York Times, one group in attendance — the American Society of Plastic Surgeons (ASPS) — muddied the waters about whether it had taken a more restrictive stance on gender-affirming care.

Questions soon followed for the AMA, the nation’s most prominent organization representing doctors.

Twenty Republican state attorneys general are pushing for the AMA to broadly oppose gender-affirming care for minors, in response to news coverage about their recommendations around youth surgeries. The attorneys suggest that the AMA may be violating state consumer protection laws by confusing, or even misleading, medical providers and patients about their stance. They mention wanting to “avoid a formal investigation” into the issue. 

The attorneys, led by Steve Marshall in Alabama, wrote a letter in February asking whether the group recommends hormone therapy or puberty blockers to treat gender dysphoria in minors. 

“If you agree that there is insufficient evidence to support using surgical interventions to treat gender dysphoria in minors — as your recent statement indicates — we do not understand how you can find that there is sufficient evidence to support using hormonal interventions to treat gender dysphoria in minors,” their letter reads. 

This is an escalation of a familiar tactic, said Khadijah Silver, director of gender justice and health equity at Lawyers for Good Government. And if it works, it will be a major weapon in the political fight to delegitimize gender-affirming care, they said. 

“If you can convince the public that they have shifted stance, that’s extremely powerful,” they said, referring to the AMA. 

In some ways, that impact is already being felt.

In a recent congressional hearing on rising health care costs, the board of trustees chair for the American Medical Association was asked about how patients across the country are struggling to find doctors. Two hours into the hearing, he was also asked about gender-affirming care for trans youth — a topic that affects few Americans, but takes up a lot of political air. 

Rep. Erin Houchin, a Republican from Indiana, asked why the medical group changed its position on surgeries for trans youth. 

But the AMA maintains that it has not changed its position. 

“In surgery and minors, our belief is that it should generally be deferred until adulthood. But, we respect the physician-patient-family relationship in determining that,” Dr. David H. Aizuss answered in response to the question from the congresswoman. 

That exchange took only a few minutes out of a hearing that spanned the gamut of crises facing the U.S. health care system, like skyrocketing insurance premiums and a worsening physician shortage. But it represents a growing tension between Republicans and medical groups, as elected officials who oppose gender-affirming care push for major health care organizations to do the same. 

The American Medical Association declined to comment on the attorneys general’s letter, which had asked for a response by March 25. In a broader statement, the medical group said it supports gender-affirming care. 

“We support evidence-based treatment for medical care, including gender affirming care,” an AMA spokesperson said in an email. “Currently, the evidence for surgical intervention in minors is insufficient for us to make a definitive statement. In the absence of clear evidence, surgical interventions in minors should be generally deferred to adulthood. Treatment decisions should be made between the physician and the patient (and family) based on the best medical evidence and clinical judgment.”

That position aligns with the World Professional Association for Transgender Health (WPATH), an authority on medical care for trans people. WPATH recommends that patients generally wait until adulthood before seeking surgery. Trans youth rarely undergo surgery of any kind; of the small number performed on adolescents, the majority are mastectomies. 

If an adolescent does need surgery, WPATH recommends they meet extensive criteria — including a full understanding of reproductive side effects, a year’s worth of hormone therapy, sustained gender incongruence, plus emotional and cognitive maturity. 

The questions surrounding surgery come on the heels of the American Society of Plastic Surgeons’ response to the January meeting with Oz. In what the Times described as a “tense” meeting, Oz pressed leaders of organizations including the AMA and the ASPS on why they recommend gender-affirming care for trans youth. At that meeting, the surgeons group said it would be changing its position, per the Times.

Weeks after the meeting, ASPS released a nine-page statement saying that gender-affirming surgery should be delayed for minors until a patient is at least 19. The surgeons’ group cited insufficient evidence that benefits for surgery outweigh risks, and pointed to a controversial report created by the Trump administration to back its position. 

The surgeons group noted that it still opposes criminalization of such medical care. The Trump administration celebrated the announcement. 

“Today marks another victory for biological truth in the Trump administration,” said former Deputy Health and Human Services Secretary Jim O’Neill, in a press release. Oz, who has compared gender-affirming care for minors to lobotomies, applauded the American Society of Plastic Surgeons “for placing itself on the right side of history.”

In the following days, the surgeon’s group appeared to backtrack. The American Society of Plastic Surgeons reportedly told NPR that its position “does not include a blanket recommendation for surgery for minors.” The ASPS did not respond to a request for comment on this story. 

The AMA has had its own trouble communicating its position. In a recent internal newsletter from the board chair, the association said that its policy on gender-affirming care has not changed at all; and that it requested a correction from The New York Times in response to the outlet’s coverage of its initial statement on youth surgeries. However, the Times says it has received no such requests.

This back-and-forth is taking place against an intense political backdrop: Six states have made it a felony for doctorsto provide gender-affirming care to trans youth. Hospitals across the country have shuttered gender clinics in response to pressure from the administration. As a result, some young patients are cut off in the middle of treatment and medical professionals are grappling with how the law impacts them. 

And despite ample news coverage, gender-affirming care is still not widely understood. 

Very few transgender youth seek and access surgeries. More rely on hormone therapy and puberty blockers to treat gender dysphoria, which is a medical condition that can cause significant distress for trans people. 

Puberty blockers delay the hormones that cause kids to go through puberty, which can be an intense and emotionally fraught time for trans youth. Many families say this treatment is crucial for their child’s wellbeing and prevents distress caused by dysphoria. There are potential risks, like decreased bone density, which is monitored by medical providers. Some providers recommend weight-bearing exercise or diet optimization to boost calcium and vitamin D levels while on puberty blockers. 

Hormone therapy, which involves taking testosterone or estrogen to cause physical changes that align one’s body with their gender identity, is another treatment that some trans youth receive to alleviate dysphoria. As with puberty blockers, clinics require a mental health assessment as well as parental or guardian consent for the treatment. 

Multiple studies have found that access to these treatments decrease depression and anxiety for trans youth. Butthey are now banned in much of the country, after Republican politicians and conservative lobbying groups flooded statehouses with bills aiming to restrict the care for minors. 

The Endocrine Society and the American Academy of Pediatrics are under federal investigation over their support for gender-affirming care. Both medical groups have sued, as the government seeks information to determine if they have made “false or unsubstantiated representations” regarding the care. 

The attorneys’ general letter to the American Medical Association is leveling up that pressure on medical groups, Silver said. 

“Because the care is so politicized, any association that stands up and asserts its support for physicians who provide the care, will be made an example of,” they said.