Part V: Cissexual Necropolitics: Rise of the Cissexual Eugenics Project at the U.S. Department of Health and Human (Dis)services.

No single action of the Trump Administration can be understood in isolation; only the larger context of the administration's genocidal campaign against trans people. Its actions may deploy mechanisms of statecraft, regulatory actions, and policy construction, but they are never so simple as regulatory or policy changes. They have always already been part of a crusade undertaken to push transgender people out of public life, a promise that the president himself campaigned on[1].

A demonstrative example of this administration’s animus towards the target population (trans youth) appears in a memo issued by U.S. Attorney General in April of 2025. This memo describes gender variance itself as “a radical ideological agenda being pushed throughout every aspect of American life” which she suggests we ought to “root out and eliminate”. Gender variance is invoked as an innate threat to adolescents, who, for this administration, are most vulnerable to a purported “coordinated, unchecked ideological attack on America's children” . To the administration, gender variance is a plague and a “sociological disease" that, absent the intervention of the federal government, will corrupt America’s children.

Centers for Medicare and Medicaid Proposed Rules.

In recent proposed rules by the Centers for Medicare and Medicaid (such as the 2025 Conditions of Participation proposed rule), the field of PTRH is inaccurately described as "sex-rejecting" procedures. This term appears nowhere in the medical canon, even in the darkest periods of pathologization towards gender variance. Instead, the term is borrowed from a conservative think-tank. The term inherently implies that trans people’s identities are disordered and emerge as a rejection of the “truth” of a person’s sex. Such a term inherently denies the humanity and personhood of people who seek out TRH, at any age. This deviation in language is intended to implicitly discredit a field of medicine that has existed for well over five decades[1], based on a rigorous evidence-clinical framework[2].

The agency offers no justification or substantiation for this proposed rule’s deviation from the medical canon. This language deviates even when compared to previous leaked drafts of these rules, wherein the draft proposed rule utilizes “sex trait modification”. This shift in language is given no justification or explication. This highly charged and inflammatory term is present as a base truism in the scope of the comment. The lack of explication and substantiation of this change in language shows that it is animus towards trans youth driving this change, not facts. Therefore, the change in language demonstrates the arbitrary and capricious nature of the proposed rule.

This same rule further advanced a narrative that TRH is not in fact medical care, despite its own prior admissions to the contrary, and to the contradiction of decades of research and medical anthropological scholarship. CMS claims:

the practice of medicine or the manner in which medical services are provided, or [control] over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.[3]

Here, CMS asserts that TRH is “not healthcare and hence are not subsumed under the term of “the practice of medicine.” and therefore, on its own authority, that the proposed rule would not regulate the practice of medicine and that these restrictions do not apply. This raises several concerns. This claim is likely a preemptive defense against critiques and challenges of the prospective rule, based on its clear interference with the state’s ability to oversee the practice of medicine. But the agency’s claim is insufficient, legally and clinically, to substantiate this preemptive defense. The administration here seeks to construct a thought-terminating cliche, to exempt itself from one of the few safeguards intended to keep the actions of the federal government in check when it endeavors to violate the rights of individual states and patients.

It does not logically follow that if CMS is prohibited from intervening in the regulation of medicine, which is under the jurisdiction of the states that set forth the standards of practice for the institutions effected by the proposed rule, that the agency is empowered to determine when its own actions are exempt from this prohibition, as it would not be an objective or appropriate evaluator on this matter. It is natural to conclude that CMS is therefore not empowered to grant itself exemptions under the law based purely on its own ideologically driven opinions regarding the definitions that constrain its actions. But the limits of authority mean little to this administration, which has spent the entirety of its first year testing courts, Congress, and the public, to understand what transgressions of authority it can get away with, and what forms of "resistance" and backlash it can absorb or neutralize. CMS is not empowered to grant itself exemptions under the law based purely on its own ideologically driven opinions regarding the definitions that constrain its actions. And yet, these claims by CMS have received little criticism from the wider public health discipline, and have mainly been criticized by trans advocates.

It is intellectually dishonest to deny that TRH is delivered to trans youth within a clinical framework designed to reduce the distress caused by the incongruence between a person’s gender identity and their assigned sex, for which an established diagnosis of gender dysphoria (GD) is required[1]. The proposed rule cites a methodologically weak, incomplete, and heavily biased white paper to support its claim of exemption, and particularly the report’s application of the foundational principles of medical ethics and the Hippocratic Oath. But, the HHS report’s application of these principles is based on an overstatement of potential adverse effects of these treatments and an outright dismissal of a larger volume of evidence demonstrating the benefits of this care. This balancing is not an objective or rigorous test, and cannot justify the claims of exception.

The agency’s claims of exemption seem to only apply when the treatments are provided to align an individual’s anatomy and physiology with their gender identity. PTRH utilizes many of the same medications provided to cisgender youth (youth who are not trans), who often access this treatment for similar purposes[5]. But Exceptions are made to provide the same treatments to cisgender youth. This illogically asserts that treatments such as GnRH agonists, which pauses puberty for early puberty youth, is considered the practice of medicine when provided to cisgender youth, but not when it is provided to trans youth for the same purpose. The key distinction would appear that when cisgender youth receive this care, the provision of these treatments do not challenge traditional stereotypes of sex and gender that administration holds[6]. When trans youth access these treatments, it may challenge these outdated stereotypes. Access to care is, therefore, contingent on conformity with stereotypes, further demonstrating the discriminatory impact of the proposed rule.

Winter of Discontent: Attacks on Public Health Infrastructure Relative to Trans-Health.

Numerous other administrative agencies have taken actions or made public statements with the intention of intimidating providers; intimidating states protecting access to this care, and continuing to restrict national access to this care where lawful. Within the first year of the second Trump Administration multiple federal agencies, including the Centers for Disease Control7], Centers for Medicare and Medicaid[8], the Food and Drug Administration[9], the Federal Trade Commission[4], the National Institutes of Health[5], and the Department of Justice[6], have all taken unprecedented actions against the health of trans people, in alignment with the administration’s unscientific[7] and biased opinions regarding gender. These actions include; erasing trans people from public health information and data collection; terminating funding for trans-inclusive research[8]; restricting insurance coverage of transition-related healthcare[9]; impede trans people’s ability to participate in sports, travel, access proper identification; and ordering multiple agencies to craft policies intended restrict the rights and life chances of trans people.[10] The purpose of this project is unambiguously to push trans people out of public life, a goal which President Trump proudly campaigned on[11].

Other policy actions announced during the December 18^th (2025) press briefing are also notable, as is how members of HHS leadership described these actions during the briefing. At this briefing, the following actions were announced:

1.      The U.S. Food and Drug Administration (FDA) is issuing warning letters to 12 companies that manufacture and sell chest binders, which the FDA alleges are illegally marketed because of their similarities with an existing Class 1 medical device intended for other medical uses;

2.      CMS announced another proposed rule that would restrict patient access to transition-related health care by restricting the use of federal funds to pay for this care;

3.      HHS Sec. signed a “declaration”, which, using ideologically charged language, alleged that these procedures do not meet professionally recognized standards of medicine and implied potential actions that HHS may take to exclude individuals and entities from participation in “any federal health care program” based on their provision of transition-related health care;

4.      HHS’s Office of Civil Rights (OCR) reversed a Biden-era policy regarding the interpretation and enforcement of disability non-discrimination protections codified by Section 504 of the Rehabilitation Act of 1973, which, in keeping with Congressional intentions for the act, the Biden administration had interpreted maximally to include gender dysphoria (GD) within the definition of a disability; and

5.      The HHS Assistant Sec signed a “public health” message further alleging that transition-related health care is neither safe nor effective. This missive substantiated its claims with only a handful of cherry-picked citations, largely to other biases in international guidelines, while ignoring the many international guidelines and reviews that contradict their findings[18]. This message advised providers not only to withhold access to this care but also to endorse practices that, by their orientation and objectives, mirror gender conversion practices.

At the press briefing for these actions, agency heads under HHS, as they breathlessly proclaimed the righteous nature of these actions, further revealed the animus-driven nature of these actions[19]. From the very beginning the HHS Secrectary declares, as other agencies under this administration have done previously[20], that the foundational “lie” of this care is that a person can “change their sex”[21]. The CMS Administrator continues this rhetoric, describing that trans people’s very existence is the result of an unaddressed deep underlying pathology and a denial of “who they really are”[22]. Following these remarks, Dr. Makary expands on the previous incendiary statements:

“Pushing transgender ideology in children is predatory, it's wrong, and it needs to stop. This ideology is a belief system that some teachers, some pediatricians, and others are selling to children without their parents knowing, sometimes, or with a deliberate attempt to remove parents from the decision-making.[23]”

Still, the most bluntly discriminatory statement was made by the Deputy Secretary of Health and Human Services, which best underscores the ideological and existential imperatives underlying these rules as a means to push trans people out of public life:

“Men are men.  Men can never become women. Women are women. Women can never become men.”

[…]

 “It takes organized efforts to deny  these fundamental truths.Sadly,   we have seen such efforts succeed from time  to time. The denial of fundamental truths can destroy nations from within. At the root of the  evils we face, such as the blurring of the lines  between sexes and radical social agendas,  is a hatred for nature as God designed it, and for life as it was meant to be lived.  This ideology does not just deny biology.  It declares war against it.”[24]

Taken with statements made by the president on the campaign trail and those made by the AG (mentioned above), much of the early predictions of parts I-IV of this work appear to be validated. This administration has, however, been less inclined to fully veil its intentions. For all the administration's efforts to dissimulate these intentions in euphemism of "fairness in sports" or "clinical uncertainty", many officials have proudly declared their intentions to fulfill Trump's campaign promise, the very same promise made by Project 2025, to eliminate trans people from public life. The silent meaning though is more prominently revealed by the quotes this section considers, a clear and genocidal intent to make trans life unliveable, and to encourage the suicides of trans people.

Citations.

[1]Donald J Trump, President Trump’s Plan to Protect Children from Left-Wing Gender Insanity, (Feb. 1, 2023), https://www.donaldjtrump.com/agenda47/president-trumps-plan-to-protect-children-from-left-wing-gender-insanity.

[2] Wylie C Hembree et al., Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline, 102 J. Clin. Endocrinol. Metab. 3869 (2017); Courtney Finlayson, Pubertal Suppression in Transgender Youth (2019); Laurens D’hoore & Guy T’Sjoen, Gender-Affirming Hormone Therapy: An Updated Literature Review with an Eye on the Future, 291 J. Intern. Med. 574 (2022); Guy T’Sjoen et al., Endocrinology of Transgender Medicine, 40 Endocr. Rev. 97 (2019); E. Coleman et al., Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, 23 Int. J. Transgender Health S1 (2022); Jason Rafferty et al., Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, 142 Pediatrics e20182162 (2018); Utah Department of Health and Human Services, Systematic Medical Evidence Review of Hormonal Transgender Treatment Report (2025), https://le.utah.gov/AgencyRP/reportingDetail.jsp?rid=636.

[3] 42 U.S. Code, Chapter 7 Subchapter XVIII - HEALTH INSURANCE FOR AGED AND DISABLED, § 1395 - Prohibition against any Federal interference.

[4] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition, https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria (last visited Oct. 1, 2024); American Psychiatric Association, What Is Gender Dysphoria?, (Aug. 2022), https://www.psychiatry.org:443/patients-families/gender-dysphoria/what-is-gender-dysphoria; American Psychiatric Association, supra note 4; Association of American Medical Colleges, supra note 4; Hidalgo et al., supra note 4.

[5] Dannie Dai et al., Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US, 7 JAMA Netw. Open e2418814 (2024); Theodore E. Schall & Jacob D. Moses, Gender-Affirming Care for Cisgender People, 53 Hastings Cent. Rep. 15 (2023).

[6] Donald J Trump, Defending Women From Gender Ideology Extremism And Restoring Biological Truth To The Federal Government, The White House (Jan. 21, 2025), https://www.whitehouse.gov/presidential-actions/2025/01/defending-women-from-gender-ideology-extremism-and-restoring-biological-truth-to-the-federal-government/.

[7] Theresa Gaffney, CDC Will No Longer Process Transgender Data, STAT (Feb. 25, 2025), https://www.statnews.com/2025/02/25/cdc-will-no-longer-process-transgender-data/; Rita Rubin, As Missing and Altered CDC Webpages Threaten Patient Care, Efforts Grow to Fill Information Gaps, JAMA (2025), https://doi.org/10.1001/jama.2025.1934; Will Steakin & Anne Flaherty, CDC Grant Funding for “gender Ideology” Programs Is “Permanently Terminated,” HHS Says, ABC News, https://abcnews.go.com/US/cdc-grant-funding-gender-ideology-programs-permanently-terminated/story?id=118386187 (last visited Feb. 3, 2025).

[8] Centers for Medicare and Medicaid Services, HHS Acts to Bar Hospitals from Performing Sex-Rejecting Procedures on Children | CMS, https://www.cms.gov/newsroom/press-releases/hhs-acts-bar-hospitals-performing-sex-rejecting-procedures-children (last visited Jan. 7, 2026); Centers for Medicare and Medicaid Services, 2025 Marketplace Integrity and Affordability Final Rule | CMS, CMS.gov (June 20, 2025), https://www.cms.gov/newsroom/fact-sheets/2025-marketplace-integrity-and-affordability-final-rule; Dave Muoio, CMS Tells Hospitals It “may” Implement New Gender-Affirming Care Policies, (Mar. 6, 2025), https://www.fiercehealthcare.com/ai-and-machine-learning/cms-tells-hospitals-its-looking-new-policies-regulations-gender-affirming; Dave Muoio, HHS, CMS Again Urge Providers against Gender-Affirming Care, (May 29, 2025), https://www.fiercehealthcare.com/providers/hhs-cms-question-hospitals-policies-finances-related-gender-affirming-care.

[9] Samantha Riedel, Trump Admin Threatens 12 Companies Over Chest Binders, Them (Dec. 22, 2025), https://www.them.us/story/trump-administration-chest-binders-trans-nonbinary-warning-tomboyx-gc2b.

[10] The Dangers of “Gender-Affirming Care” for Minors, (2025), https://web.archive.org/web/20250905011300/https://www.ftc.gov/media/dangers-gender-affirming-care-minors.

[11] Dave Levitan, NIH, Other HHS Divisions Told to Terminate Contracts or Grants Because of “Gender Ideology,” Splinter, https://www.splinter.com/nih-other-hhs-divisions-told-to-terminate-contracts-or-grants-because-of-gender-ideology (last visited Jan. 31, 2025); Angus Chen, NIH Terminates Ongoing Grants for LGBTQ+ Research, STAT (Mar. 3, 2025), https://www.statnews.com/2025/03/03/nih-terminates-ongoing-grants-for-lgbtq-research/?utm_campaign=CHL%3A%20Daily%20Edition&utm_medium=email&_hsenc=p2ANqtz-89ABasszbKWki6wxZ4v12APOuC5c4jOOq9IW8JwxVYIB2KSHBh-l_XEq8vv2GZqaY6AbRmz_u0uwJCFm1guvrocXvjPA&_hsmi=350031150&utm_content=350031150&utm_source=hs_email; Sara Reardon, New NIH Grant Terminations Target Transgender Studies—Even in Mice, Science.org (Mar. 6, 2025), https://www.science.org/content/article/new-nih-grant-terminations-target-transgender-studies-even-mice; Phie Jacobs, Trump Administration Quashes NIH Scientific Integrity Policy, Science.org, https://www.science.org/content/article/trump-administration-quashes-nih-scientific-integrity-policy (last visited Oct. 2, 2025).

[12] Chris Geidner, Read A.G. Bondi’s Memo Purporting to Implement Trump’s Anti-Trans Attacks, (Apr. 14, 2025), https://www.lawdork.com/p/read-ag-bondis-memo-purporting-to.

[13] Claire Ainsworth, Sex Redefined: The Idea of 2 Sexes Is Overly Simplistic, Scientific American (Oct. 22, 2018), https://www.scientificamerican.com/article/sex-redefined-the-idea-of-2-sexes-is-overly-simplistic1/; Max Barnhart, Scientists Reject a Binary View of Human Sex at NIH Symposium, Chemical & Engineering News (Oct. 20, 2024), https://cen.acs.org/biological-chemistry/genomics/Scientists-reject-binary-view-human/102/i33; Kate Clancy et al., Biology Is Not Binary, American Scientist (Feb. 5, 2024), https://www.americanscientist.org/article/biology-is-not-binary; Agustín Fuentes, Here’s Why Human Sex Is Not Binary, Scientific American (2023), https://www.scientificamerican.com/article/heres-why-human-sex-is-not-binary/; Alexandra Kralick, We Finally Understand That Gender Isn’t Binary. Sex Isn’t, Either., Slate, Nov. 2018, https://slate.com/technology/2018/11/sex-binary-gender-neither-exist.html; Amanda Montañez, Beyond XX and XY: The Extraordinary Complexity of Sex Determination, Scientific American (Sept. 1, 2017), https://www.scientificamerican.com/article/beyond-xx-and-xy-the-extraordinary-complexity-of-sex-determination/; Christoph Rehmann-Sutter et al., Is Sex Still Binary?, 35 Med. Genet. 173; American Psychological Associaton, supra note 4; American Psychological Associaton, supra note 3.

[14] Levitan, supra note 26; Chen, supra note 26; Steakin and Flaherty, supra note 22.

[15] Centers for Medicare and Medicaid Services, supra note 23; Centers for Medicare and Medicaid Services, supra note 23.

[16] Kayler Cassidy, Department of Homeland Security No Longer Bans Surveillance On LGBTQ+ People - GO Magazine, GoMag (Feb. 28, 2025), https://gomag.com/article/department-of-homeland-security-no-longer-bans-surveillance-on-lgbtq-people/; Centers for Medicare and Medicaid Services, supra note 23; Chen, supra note 26; Lindsey Dawson & Jennifer Kates, Overview of President Trump’s Executive Actions Impacting LGBTQ+ Health, KFF (Mar. 18, 2025), https://www.kff.org/other/fact-sheet/overview-of-president-trumps-executive-actions-impacting-lgbtq-health/; Department of Justice: Office of Public Affairs, The Department of Justice Proposes Legislation to Protect Children from Gender Mutilation | United States Department of Justice, justice.gov (Sept. 3, 2025), https://www.justice.gov/opa/pr/department-justice-proposes-legislation-protect-children-gender-mutilation; Department of Veteran Affairs, VA to Phase out Treatment for Gender Dysphoria - VA News, https://news.va.gov/press-room/va-to-phase-out-treatment-for-gender-dysphoria/ (last visited Apr. 21, 2025); The Dangers of “Gender-Affirming Care” for Minors, supra note 25; Gaffney, supra note 22; Kristen Hwang, LA Clinics Lose Funding for Transgender Health Care as Trump Executive Orders Take Hold, CalMatters, Feb. 4, 2025, http://calmatters.org/health/2025/02/trump-executive-order-transgender-health/; Jacobs, supra note 26; Carla Johnson, Devna Bose & Laura Bargfeld, Some Hospitals Pause Gender-Affirming Care to Evaluate Trump’s Executive Order | AP News, AP News (Jan. 30, 2025), https://apnews.com/article/transgender-trump-executive-order-hormones-hospitals-8d9e6b94b34d2e6f890c06ebeba0fe1d; Christopher Kane, Trump Promises Anti-Trans Executive Orders on Day 1, (Dec. 23, 2024), https://www.washingtonblade.com/2024/12/23/trump-promises-anti-trans-executive-orders-on-day-1/; Mack Liederman, UChicago Medicine Latest To End Gender-Affirming Care For Minors, Block Club Chicago (July 18, 2025), https://blockclubchicago.org/2025/07/18/uchicago-medicine-latest-to-end-gender-affirming-care-for-minors-amid-federal-pressure-campaign/; Muoio, supra note 23; Muoio, supra note 23; Reardon, supra note 26; Ivana Saric, All of the Anti-Trans Executive Orders Trump Has Signed, Axios (Feb. 5, 2025), https://www.axios.com/2025/02/05/anti-trans-executive-orders-trump; Julie Steenhuysen & Ted Hesson, US Health Agencies Scrubbing Websites to Remove “gender Ideology” | Reuters, Reuters (Jan. 31, 2025), https://www.reuters.com/world/us/us-health-agencies-scrubbing-websites-remove-gender-ideology-2025-01-31/.

[17] Donald J Trump, President Trump’s Plan to Protect Children from Left-Wing Gender Insanity, (Feb. 1, 2023), https://www.donaldjtrump.com/agenda47/president-trumps-plan-to-protect-children-from-left-wing-gender-insanity.

[18] Brezin et al., supra note 3; Aneta Gawlik-Starzyk et al., Framework Guidelines for the Process of Caring for the Health of Adolescent Transgender (T) and Non-Binary (NB) People Experiencing Gender Dysphoria — the Position Statement of the Expert Panel, 76 Endokrynol. Pol. 1 (2025); German Society for Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, S2k-Leitlinie Geschlechtsinkongruenz Und Geschlechtsdysphorie Im Kindes- Und Jugendalter – Diagnostik Und Behandlung, (2025), https://register.awmf.org/de/leitlinien/detail/028-014; Michelle M Telfer et al., Australian Standards of Care and Treatment Guidelines for Transgender and Gender Diverse Children and Adolescents, 209 Med. J. Aust. 132 (2018); Hembree et al., supra note 2; Rafferty et al., supra note 2; American Psychological Associaton, supra note 4; Erin Reed, Endocrine Society And American Academy Of Pediatrics Respond To Cass, Reject Bans, (July 25, 2024), https://www.erininthemorning.com/p/endocrine-society-and-american-academy; Utah Department of Health and Human Services, supra note 2; Swiss National Advisory Commission on Biomedical Ethics, [New CNE Opinion Paper on the Medical Treatment for Minors with Gender Dysphoria] National Advisory Commission on Biomedical Ethics NCE, (2025), https://www.nek-cne.admin.ch/en/about-us/news/news-details/die-nek-veroeffentlicht-stellungnahme-zur-medizinischen-behandlung-von-minderjaehrigen-personen-mit-einer-geschlechtsdysphorie.

[19] Department of Health and Human Services, Protecting Children, (2025), https://www.youtube.com/watch?v=aY1XfN6Tt0Q.

[20] The Dangers of “Gender-Affirming Care” for Minors, supra note 25.

[21] Id., from 2:41 to 2:53 minutes.

[22] Id., at 13:05 minutes.

[23] Id., at 19:24 minutes.

[24] Id., at 36:39 minutes onward.