The election could shift the fight over transgender care from the states to Washington

While the legislative fight over transgender care has so far been largely confined to states, a flood of campaign ads from Republicans and concerned transgender advocates suggests that could change as Republicans take control of Congress and the White House .

While Republican presidential candidate Donald Trump focused on restricting gender-affirming care for transgender people, particularly in the final weeks of his campaign, leading Republican senators have launched investigations into the legitimacy of using puberty blockers on minors.

And in December, the Supreme Court will hear arguments in a landmark case that could decide the fate of children's access to gender-affirming care.

Democrats, advocates and LGBTQ+ advocacy groups say the federal focus on transgender care represents a significant shift from the past, when most policies impacting transgender people were adopted at the state level.

According to the Human Rights Campaign, 26 states have passed laws banning gender-specific care for minors up to age 18. However, there is no such ban at the federal level. Republicans have tried in recent years to include policy amendments to restrict transgender access to health care services in major spending bills, but Democrats have blocked them.

A Republican-led Congress in 2025 could change that.

“We will see future attempts to influence trans people's ability to access health care at both the federal and state levels,” Olivia Hunt, policy director at Advocates for Trans Equality, said of a possible Republican convention of the White House in 2025.

In the run-up to the election, the Trump campaign is blanketing the southern half of the US on NFL Sundays with ads that say “Kamala is for them/them, Trump is for you.” The ads also claim Harris supports taxpayer-funded operations on gender reassignment for transgender inmates — a policy that was actually included in the first Trump administration's budget documents.

The transgender community makes up less than 1 percent of the U.S. population, and polls show voters say they are not particularly interested or motivated about the issue.

According to a poll by the left-leaning group Data for Progress, more than 60 percent of voters, including 41 percent of Republicans, called the use of political attack ads against transgender people “shameful.”

“Republicans have been practicing abortion for so many years [as a political rallying cry] And right now it’s backfiring,” said Sasha Buchert, senior attorney at Lambda Legal, an organization dedicated to protecting the LGBTQ+ population. “So they took on this issue, this partisan issue, to go after 1 percent of the population.”

Outlook from the congress

As the 118th Congress draws to a close, Republicans on Capitol Hill are becoming increasingly interested in transgender health policy, and that's likely an indication of what could happen with a GOP majority next year.

Sen. Bill Cassidy, R-La., is poised to lead the Senate Health, Education, Labor and Pensions Committee if the GOP takes control of the chamber. Earlier this month, he launched an investigation into medical organizations that recommend the use of puberty blockers or gender-confirming surgeries for minors.

Cassidy's research was inspired by a 2020 study by Britain's National Health Service that found that for the majority of young people, medical interventions may not be the best way to treat gender dysphoria.

The investigation, often referred to as the “Cass Review”, led to the UK banning the prescribing of puberty blockers to under-18s, with a few exceptions. The report was criticized by international health authorities as well as medical groups in the United States, Canada, Australia and Japan for its weak evidence.

Cassidy describes his investigation as a fact-finding mission for Americans to ensure that “treatment guidelines are based on and supported by science and are not influenced by extreme ideology.” But advocates worry it could impact access to health care.

Groups such as the American Academy of Pediatrics and the World Health Organization recommend puberty blockers to treat gender dysphoria in minors. Surgical procedures are extremely rare among transgender children – a recent study by researchers at the Harvard School of Public Health found that only 2.1 out of 100,000 diagnosed transgender teens ages 15 to 17 receive gender-confirming surgery. For adults ages 18 and older, the rate is 5.3 surgeries per 100,000 people diagnosed as transgender.

Additionally, Republican Senator Marco Rubio of Florida is calling on the National Institutes of Health to investigate whether its own researchers are manipulating data on puberty blockers for minors.

Rubio is questioning the unpublished results of a federally funded study analyzing the effects of puberty blockers. The study's lead doctor, Johanna Olsen-Kennedy, recently told The New York Times that she did not immediately release the study's results because of the heated political environment surrounding the issue. Their study did not find that puberty blockers improve the mental health of transgender youth; Rather, mental health remained constant.

On October 28, Rubio sent NIH Director Monica Bertagnolli a letter accusing Olson-Kennedy of “abusing her position of trust to conceal political ideology” and calling on the research agency to investigate the matter.

Rep. Mark Pocan, D-Wis., chairman of the Congressional Equality Caucus, said the Senate effort should come as no surprise given Project 2025's goals. Although Trump has rejected the document, many Democrats fear that the list's proposals for a Republican administration could serve as guidance for lawmakers.

Lawmakers on Capitol Hill have repeatedly tried in recent years to tie policymakers to big spending bills that ban access to puberty blockers for minors or gender-affirming care for military members and their families. But they failed to pass such policies.

Democrats say they plan to do everything in their power to block such policies in a new administration.

“Thankfully, Democrats managed to prevent their efforts to restrict access to health care from becoming law — and we will not stop protecting transgender rights in the future,” Pocan said in a statement.

Executive Politics and Impact on the Supreme Court

On December 4th, the Supreme Court is scheduled to hear the case USA v. Skrmetti. It will examine whether Tennessee law banning medical treatments for transgender youth, including puberty blockers and hormone therapy, violates the Equal Protection Clause of the 14th Amendment.

The case could decide the future of health care for transgender youth across the country, regardless of who wins the White House.

But if Trump wins, his administration could take other steps to restrict access to health care.

Project 2025 describes gender-equitable care of minors as “child abuse”. Similarly, the 2024 GOP platform promises to “prohibit taxpayer funding of gender reassignment surgeries and prevent taxpayer-funded schools from promoting gender transition.”

Trump officials took a number of steps during his first term to restrict access to health care for transgender people.

For example, the Department of Health and Human Services proposed rules to eliminate protections for transgender people and others who face discrimination in health care or through insurers' denial of coverage.

Trump's Justice Department filed a brief with the Supreme Court arguing that federal law “does not prohibit discrimination against transgender people based on their transgender status.”

The nondiscrimination clause of the 2010 health care law, known as Section 1557, is likely the most vulnerable target, said Ma'ayan Anafi, senior health equity and justice attorney at the National Women's Law Center. Repeal of this law could impact gender-equitable care and reproductive access.

Anafi and several other lawyers noted that a new Trump administration could try to use the mifepristone manual for hormone therapy and use the Food and Drug Administration to restrict off-label use of hormone therapy in transgender people.

“It's basically about finding ways to weaponize the tools that are available,” Hunt said.

Sandhya Raman contributed to this story.