This post kicks off a series on the law and political economy of trans healthcare.
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It is not breaking news to say that Donald Trump has trans people in his crosshairs. During his most recent campaign, Trump infamously claimed that Kamala Harris supported “transgender operations on illegal aliens that are in prison.” Indeed, he spent over $220 million to repeatedly inform the American public that, “Kamala was the first to help pay for a prisoner’s sex change. Kamala’s agenda is for they/them, not you.”
Now in office, Trump is attacking not only civil rights but trans life itself. He has issued a barrage of Executive Orders defining trans people out of existence and instructing federal agencies to stop providing health care to trans adults in federal prison and immigration detention, to stop funding health care providers that provide healthcare to trans youth, to strip already-awarded funding from research about trans issues, to punish public interest lawyers who work on trans issues, and to ban trans people from the military in part because of their health care needs. The Education Department is already initiating investigations of public schools with gender neutral bathrooms, while HHS threatens to pull federal funding for hospitals providing medically necessary healthcare, and the EEOC claims that federal employment law does not protect against gender identity discrimination, despite the Supreme Court’s clear holding that it does.
Why is the administration singling out transgender people for such aggressive measures? This is a question we are both frequently asked, and one that merits more public reflection than it has so far received. Popular explanations include the campaign’s need to attack bodily autonomy without defending draconian abortion bans, the administration’s desire to act decisively given its structural weakness, and MAGA’s self-conscious attempt to mirror similar attacks on gender and sexual nonconformity among interwar German fascists. While each of these stories have merit, a political economy lens does a better job of demystifying MAGA’s obsession with transgender people, and, we hope, will more effectively move the needle on meaningful resistance to these attacks.
Let’s start by taking a closer look at the conservative narrative about transgender healthcare. Their story is that transgender people, and minors in particular, are able to access puberty blockers, hormone therapy, and major surgeries with little to no resistance from medical providers, hospitals, or insurance companies. Access to transition care is apparently so frictionless that teachers are providing it to children in their public school classrooms. Needless to say, none of these things are actually happening. All studies of the issue find that transgender people, especially minors, struggle to get the care they need because it is not available from enough providers and the steps to access it from competent providers are long and involved.
Nevertheless, in the MAGA narrative — where even transgender women in immigration detention have seamless access to care — trans people seeking healthcare are transformed into patients who cut the line, receiving more than their fair share of health services while everyone else waits months for appointments, appeals pre-authorization denials, and prays that they can afford both food and medicine this month. Much as Reagan invoked the welfare queen — a racialized and gendered figure supposedly sucking the public coffers dry — as a diversion to absorb public outcry against devastating cuts to the social safety net, Trump today offers transgender people as scapegoats for the deplorable state of American healthcare.
Understood in this light, we can see that trans health care bans (i.e., laws and regulations that prohibit trans people from getting the care that non-trans people get) provide effective strategies to launder anti-social welfare politics under the cover of anti-trans bias and cost savings. Trans health care bans’ proponents maintain the veneer that necessary medical care is still provided to “deserving patients” — i.e., non-trans youth seeking health care to conform to gender norms — while obscuring how these types of medicines and procedures often do the work of maintaining the fiction of sex immutability and sex essentialism. And in addition to limiting who can get certain health care, the bans often regulate through which means (e.g., insurance coverage, hospitals vs. free clinics, etc.) anyone can access care. For trans people, bans operate as one-way ratchets, forcing them to navigate harsher and harsher conditions that increase the health risks and literal costs of changing sex; for non-trans people, bans further constrict what health care is available through official means.
Attacking trans people for supposedly hogging all the healthcare helps Trump pursue his unpopular, unconstitutional, and anti-constitutional health policy goals. For instance, in his first administration, Trump failed in his promise to repeal the Affordable Care Act. But by linking trans health care to popular provisions, like the law’s anti-discrimination protection in Section 1557, and its ban on excluding preexisting conditions, Trump is now pushing for policies to repeal the ACA by a thousand cuts. Similarly, post-Dobbs, opposing abortion access remains highly unpopular. So, rather than ban abortion nationwide or revive the Comstock Act, Trump’s first steps to limit bodily autonomy are aimed at trans people by limiting access to transition-related care for trans youth, trans people in federal custody, and trans people receiving federally-funded health care. Under the cover of anti-trans bias, Trump is ringing the death knell of universal government services.
This should be a top concern for everyone who thinks the healthcare system is already broken, in need of reimagination and investment, not a fire sale on depreciated assets. Instead, potential allies watch from the sidelines and assume the slash and burn won’t reach them on higher ground. Indeed, many of the voices and institutions in the best position to defend trans people’s equal place in public life — including the Democratic politicians, liberal commentators, corporate leaders, and law firms who stood up for trans people as recently as 2016 — have remained silent or joined the mob.
By de-exceptionalizing trans people’s place in the broader political economy of healthcare, our hope is to make obvious that Trump’s relentless attacks on gender affirming care for trans people threaten both trans lives and the social provision we all depend on.
