Medicaid and the Children’s Health Insurance Program collectively spent over $135 million in taxpayer funds on gender-transition treatments and surgeries for minors during a five-year span ending in 2023, according to a new Congressional Budget Office analysis.
This sum is probably the end, at least for now, of substantial public spending on such medical interventions, given intense and widespread opposition to the field of pediatric gender medicine from Republican lawmakers. President Trump has made it his mission to block these controversial treatments and surgeries from being provided to minors. The practices in question include gender-transition surgeries — mostly mastectomies — and giving gender-distressed youth puberty blockers and cross-sex hormones.
The Williams Institute at the UCLA School of Law estimates that there are in the United States 300,000 13 to 17 year olds who identify as transgender. In 2024, the World Professional Association for Transgender Health, or WPATH, a quasi-medical-activist organization that publishes influential trans-care guidelines, suggested in a release that the majority of these youth would do best to undergo a medical transition.
WPATH insists that the evidence supports the benefits of such interventions. But a slew of systematic literature reviews — the gold standard of scientific research — have found that the supporting research is weak and inconclusive. This has led several European nations to sharply curtail access. This came as a majority of U.S. states – all but one (Alaska) of the so-called “red states” – have made the treatments illegal for minors. Last year, the Supreme Court upheld the legality of these bans.
Published on Monday in a research letter in JAMA Pediatrics, the new C.B.O. analysis covered 2019 to 2023 medical-claims data on eight- to 17-year-olds identifying as transgender. Its conclusions regarding the age and birth-sex breakdowns of the use of puberty blockers and cross-sex hormones were quite similar to those documented in a 2025 paper examining the use of such medications by privately insured minors.
According to the new analysis, spending on gender-transition drugs and surgeries for youths by Medicaid and CHIP steadily increased during the five-year study period, which led into the time when state bans of the interventions for minors started going into effect.
“These numbers may mark the high-water mark of a medical experiment that expanded far faster than the evidence ever justified,” said Jamie Reed, who was a case manager at the pediatric gender clinic at Washington University at St. Louis and became a whistleblower, accusing her former employer of shoddy and harmful practices.
Both of the recent insurance-claims studies suggested that during the recent five-year spans they analyzed, over one in 1,000 biological girls were taking testosterone by the time they reached age 17. Their biological-male counterparts were taking cross-sex hormones at about half the biological girls’ rate. This finding is in keeping with widespread reports from the past 15 years that the majority of minors presenting to pediatric gender clinics in Western nations have been post-pubescent biological girls.
Leading pediatric gender medicine practitioners have fiercely disputed theories that the advent of smartphone-based social media platforms drove the subsequent explosion of gender-related distress and transgender identification in teenage girls in particular. But Ms. Reed, who is now one of the leading activists fighting for an end to this medical field, recalled the principles that she said guided the Wash U gender clinic. “What was framed as urgent endocrine care often looked more like the medicalization of a social contagion,” she said. “The warning signs were there. The brakes should have come much sooner.”
After brakes were applied, though, the effects have been decisive. Since 2021, 27 states have banned minors from receiving gender-transition interventions. More recently, the second Trump administration has used the threat of pulling hospitals’ federal grants to force the closure of pediatric gender clinics in blue states.
The new C.B.O. analysis found that combined CHIP and Medicaid spending on gender-transition interventions for minors increased from $17.2 million in 2019 to $34.1 million in 2023; the bulk of the spending went to puberty blockers, which are extraordinarily expensive.
Both of the recent analyses of spending on gender-transition interventions for minors found that puberty blocker use for gender-transition treatment remained low compared with far less expensive cross-sex hormone prescriptions. Blockers were most commonly used by 12 to 14 year olds. Relative to blockers, hormone prescriptions shot up among biological girls starting at age 14 and did the same among biological boys starting at age 15, albeit at a less steep trajectory.
Gender-transition surgeries among minors were much less common than the use of gender-transition drugs.
In October 2024, the nonprofit advocacy group Do No Harm, which fervently opposes such medical interventions, released a non-peer-reviewed analysis of insurance database claims, covering both public and private payers. The nonprofit reported that physicians billed $120 million for gender-transition treatments and surgeries in minors during the same five-year period newly analyzed by the C.B.O. The data suggested that 14,000 minors had received any such intervention during that time.
Given that the C.B.O. analysis was limited to claims submitted only to public payers and yet reached a similar dollar figure as Do No Harm, this appears to suggest that the true figure of youths who have received these interventions could be much larger than what the nonprofit reported.
“We always knew our estimates represented the floor, not the ceiling,” said Dr. Travis Morrell, a senior fellow at Do No Harm. He continued: “One of the biggest questions left unanswered by this and other studies is that they do not capture the number of patients treated with inaccurate billing codes, something WPATH still recommends today on their website.”
For the new study, Jared Lane K. Maeda, an analyst at the C.B.O, examined 2019 to 2023 data on 80,546 youth identifying at transgender and covered by Medicaid or CHIP. He identified gender-related services through a set of diagnostic and procedure codes that were validated in a 2024 study out of Harvard.
The average age of the youth in the new analysis was 14 years old and there were a cumulative 129,000 years of data on these minors, or an average of 1.6 years per youth.
The study looked at puberty blocker and cross-sex hormone use starting at age 8. By age 17, about 0.14 percent of biological girls were taking testosterone and about 0.06 percent of biological boys were taking estrogen — compared with 0.14 percent and 0.08 percent, respectively in the previous study concerning privately insured youth, which covered 2018 to 2022.
The new study found that the rate of gender-transition surgery among minors was low, at just 0.22 per 100,000 Medicaid and CHIP recipients among those 13 to 14 years old and 3.44 per 100,000 among those 15 to 17 years old. However, the authors did make a point that the rate among the older cohort was higher than previously reported in a 2024 Harvard analysis that supporters of such surgeries often point to as evidence that these surgeries are rare. That study found that the rate among 15 to 17 year olds was 2.1 per 100,000.
In non-peer-reviewed 2024 analysis of medical claims data, Leor Sapir, a senior fellow at the Manhattan Institute conservatively estimated that about 1,000 minors underwent gender-transition mastectomies annually in recent years. He found that youth as young as 12 and a half years old have undergone such surgeries.
The new study is limited by its use of claims data, which might misclassify some youth as identifying as transgender, Dr. Maeda wrote. He did not return a request for comment, nor did the authors of the private-insurance study or the Harvard analysis.
Overall, cross-sex hormones were used by 28 per 100,000 biological girls eight to 17 years old who were covered by Medicaid or CHIP and by 16 per 100,000 of their biological-male counterparts. Overall puberty blocker use was much lower, at seven per 100,000 biological girls and six per 100,000 biological boys.
These figures, paired with those from the analysis regarding privately insured youth, suggest that only a fraction of minors who undergo gender-transition treatment have their puberty blocked during early puberty.
The original premise of the pediatric gender medicine field, founded by Dutch researchers in the late 1990s, was that minors could be routed into a cross-sex puberty and thus be better able to “pass” as the opposite sex. This, in theory, would help them avoid the need for certain surgeries to modify their sex traits. But the recent studies suggest that the bulk of minors undergoing gender-transition interventions are evidently biological girls who first go on testosterone after it is largely too late for them to avoid the impacts of a female puberty, in particular breast development.
“In the gender clinic, I watched as the majority of patients were adolescent girls placed on testosterone late in or after puberty,” said Ms. Reed.
The new analysis found that Medicaid spent $4.3 million on gender-transition surgeries, $4.9 million on cross-sex hormone treatment and $109 million on puberty blockers during the study period. Out of the $118.3 million total, $72.3 million was covered by the federal government; states covered the rest.
CHIP spent $727,00 on surgeries, $609,000 on hormones and $15.9 million on blockers during this period. The federal government covered $13.8 million of the $17.3 million total.
Spending on gender-transition interventions for minors increased steadily from year to year. However, puberty blocker spending by Medicaid leveled off between 2022 and 2023. Some state bans were in place by that latter year.
Data from Do No Harm suggests that in the blue states where such treatments remained legal in 2023, prescriptions to gender-transition treatments receded compared with 2022. It is unclear whether this represented physicians becoming more cautious in their prescribing practices, a reduction in demand, or a combination of the two.
Last month, a jury in Westchester County, New York, awarded $2 million in damages to a 22-year-old woman, Fox Varian, who at 16 underwent a gender-transition mastectomy that she came to bitterly regret. It is possible that her victory in court against her psychologist and plastic surgeon will serve as a cautionary tale and lead care providers still treating minors with these interventions to observe greater guardrails.
But a fast dwindling number of doctors are still providing such treatments as the Trump Administration maintains its aggressive effort to shut down all of pediatric gender medicine. The U.S. Department of Health and Human Services in December proposed a new rule that would bar federal funding to any hospital that provides these interventions to patients under age 19. This effort, along with a similar executive order from President Trump, has led to a steady march of major hospitals shuttering their pediatric gender clinics. Children’s Hospital Los Angeles was the first, in June, to announce such a closure. This month, NYU Langone and Mt. Sinai each indicated they are instigating such closures in New York City, to widespread protests by state and local Democratic lawmakers. This includes those running in a crowded primary to replace Representative Jerry Nadler, who is retiring, including President Kennedy’s only grandson, Jack Schlossberg.
