From the start of his 2024 presidential campaign, Donald Trump vowed to restrict access to gender-affirming care.

“I will sign a new executive order instructing every federal agency to cease all programs that promote the concept of sex and gender transition at any age,” Trump said in a video posted to his platform Truth Social in early 2023. “I will then ask Congress to permanently stop federal taxpayer dollars from being used to promote or pay for these procedures.”

He also promised to pass a law banning gender-affirming care for minors in all 50 states. Throughout the campaign, Trump zeroed in on the very existence of trans people as a wedge issue—and a poll conducted by Ground Media found that after exposure to Trump’s anti-trans ads, viewers were less likely to support policies protecting access to health care for trans people. Some even reported they’d be less accepting of a trans friend or family member.

Now that Trump is re-entering office, trans people and their health providers are bracing for potential attacks on gender-affirming care for children and adults alike, which they suspect could follow a familiar pattern—the anti-abortion playbook.

Trump could withhold federal funds for gender-affirming care

Trump’s promise that a national ban on youth gender-affirming care would “go very quickly” may not come to fruition, because even though his party captured majorities in both chambers of Congress, its Senate majority isn’t filibuster-proof. In the immediate aftermath of the election, gender-affirming care providers told Rewire News Group they hoped this fact might help stave off total bans.

However, federal attacks on gender-affirming care have begun in advance of Trump’s arrival. And Democrats have largely chosen not to push back.

In December, just 10 Senate Democrats voted against the National Defense Authorization Act (NDAA), an annual funding package that for 2025 included a provision banning coverage of gender-affirming care for children of active-duty military members who rely on the government-funded health insurance program TRICARE. Eighty-one Democrats voted in favor of this version of the NDAA in the House of Representatives. And though President Joe Biden said his administration “strongly opposes” the gender-affirming care ban written into the bill, in one of his final acts as president, he signed it.

For those who have long followed legislative attempts to restrict abortion access, this will sound familiar. Since 1977, a provision known as the Hyde Amendment has prevented federal funds from being used to pay for abortion care except when pregnancy is the result of rape or incest, or when a pregnant person’s life is in danger.

Initially, Hyde only applied to Medicaid. But over time, similar language was extended to cover all federally-funded health benefit programs, including TRICARE, Medicare, the Indian Health Service, the Children’s Health Insurance Program, the Federal Employees Health Benefits Program, and the Peace Corps. It also affects people incarcerated in federal prisons.

The Hyde Amendment has never been a standalone law. It’s a “rider” attached to the kind of big spending bills that Congress must pass in each session to fund critical programs—like the NDAA.

“It is within Trump’s capacity, if he follows the current rule of law, to withdraw federal funding for gender-affirming care,” said Dr. Crystal Beal, a family physician and founder of the telemedicine practice QueerDoc, which serves patients in ten states.

And when federal funds are cut, state funds often follow. Returning to the example of abortion care, in the decades after the Hyde Amendment was first enacted, many states also enacted policies banning public funding for abortion care.

In the decade or so leading up to the overturn of Roe v. Wade, several states took it a step further, banning abortion coverage in private insurance plans, or at least those available on Affordable Care Act-mandated health exchanges.

Jona Tanguay, a physician associate, clinical instructor, and gender-affirming care and substance use disorder expert, said they worry the same could happen to trans health care.

“We’ve already seen places like Florida ban Medicaid coverage for gender-affirming care,” they said. Florida’s ban was struck down in federal court, but it is still in effect as the state continues to appeal that ruling.

And more bans, Tanguay said, could create an excuse for private insurers to refuse to cover gender-affirming care even in states where it remains legal.

“At the end of the day, the insurance companies don’t actually want to cover anything, they want to make money,” Tanguay said. “And so if they feel like they can get away with it, they’re absolutely going to stop covering [gender-affirming care].”

Project 2025’s plan to end gender-affirming care

Revoking federal funding for gender-affirming care is one of many steps outlined in the Project 2025 plan.

“Radical actors inside and outside government are promoting harmful identity politics that replaces [sic] biological sex with subjective notions of ‘gender identity’ and bases a person’s worth on his or her race, sex, or other identities,” Project 2025’s “Mandate for Leadership” reads. “This destructive dogma, under the guise of ‘equity,’ threatens American’s [sic] fundamental liberties as well as the health and well-being of children and adults alike.”

Another Project 2025-recommended change that would affect gender-affirming care—and potentially all access to health care for trans people—is to transform Section 1557 of the Affordable Care Act.

Section 1557 protects Americans from discrimination in health-care settings, and under the Obama administration, the Department of Health and Human Services’ (HHS) interpretation of this provision was broad, explicitly including anti-discrimination protections for patients based on gender identity and termination of pregnancy.

However, the first Trump administration swiftly changed this rule, removing the explicit protections for trans people, adding broad “religious freedom” protections for health-care providers who refuse to participate in certain kinds of medical care and effectively allowing insurers to discriminate against LGBTQ+ people and those living with HIV.

From day one, experts urged the Biden administration to re-adopt Obama-era Section 1557 protections. Eventually, Biden’s HHS did so—but the rule wasn’t finalized until 2024. Trump is expected to shift it back.

Dr. Julius Johnson-Weaver, founder of the Maryland-based practice Resolve MD, which offers gender-affirming care, worries that another piece of the anti-abortion playbook that could carry over into gender-affirming care is some pharmacists’ refusal to fill prescriptions. This is a phenomenon that could be enabled or even encouraged depending on the changes the Trump administration makes to policies like Section 1557.

Testosterone’s status as a controlled substance

At the start of the pandemic, the Drug Enforcement Administration (DEA) relaxed some of its rules around telemedicine prescriptions for controlled substances. Many trans health advocates were worried about the planned end of these flexibilities—which were set to expire at the end of 2024—because testosterone is a controlled substance. But in November, the DEA extended these changes for one more year.

Though Beal is concerned about escalating bans on gender-affirming care, they aren’t particularly worried about Trump reversing this one change.

“Telemedicine access has historically had bipartisan support, and Trump himself has supported additional expansion of telemedicine access in the past,” Beal said.

They also added that the popularity of easier testosterone access among cisgender men may help protect that access for trans people.

“Hormone replacement therapy (HRT) for cis men has also become a very standard thing, especially if you’re going to an ‘anti-aging’ doctor,” Beal said.

However, the fact that testosterone is a controlled substance still poses a risk for the trans people who need it in an increasingly hostile environment, Johnson-Weaver said.

“You could be completely cis-passing as a trans man, for instance, and not wanting anyone to know. Maybe you’re just taking testosterone as a cis guy, right?” he said. But picking up a prescription for a controlled substance usually requires more stringent identity verification.

“Now you’re handing over an ID and outing yourself” if you haven’t—or can’t—change the gender marker on that ID, Johnson-Weaver said.

The fact that testosterone is a controlled substance while estrogen is not also creates a disparity in access to hormones—one that isn’t based in science. Testosterone was only added to the the list of controlled substances in 1990 due to concerns over its use as a performance-enhancing drug in sports. At the time, the DEA, the Food and Drug Administration, and the American Medical Association all opposed this change.

“I think that sometimes people think of the DEA as being like the CDC, a scientific organization,” said Tanguay. “It should not be thought of that way. It is something very different.”

They noted that the DEA has only existed since President Richard Nixon’s administration, and that the agency’s architects have admitted its purpose was to criminalize people of color and anyone else the federal government viewed as a threat.

What’s on the line

For trans people, the stakes are high.

“I know me and many other individuals are already making plans on non-traditional routes of accessing our meds if the federal government attempts to stop trans adults from transitioning,” said Lee, a trans man in Arizona who asked to be identified by his first name only for safety.

These measures include “stockpiling, traveling across borders, buying from others who can travel to get them, rationing to stretch them out,” and more, Lee said.

Even in the relatively protective state of Maryland, Johnson-Weaver said, “I’m still getting those calls. Patients are asking me, ‘How can I get more medication? How can I stockpile?’”

Within the trans community, there is a long history of “do-it-yourself” hormone therapy, because trans people have so often been without access to supportive health care, and because they are more likely to live in poverty and be uninsured.

On the one hand, this is a “hopeful thing,” said Justice Williams, activist and founder of Fitness 4 All Bodies. If the path to transition-related care within the medical system is cut off, there are established alternatives. But on the other hand, “doing things in desperation doesn’t necessarily mean that you’re doing the best thing for your body,” Williams said. For example, he worries that new limits on gender-affirming care could lead to a rise in the sharing of needles and injectable medications, which poses serious risks.

“Where does that drive the health and wellness of transgender individuals who already are stigmatized, who already have less care?” said Williams.

But for many trans people, the risk of losing access to hormone therapy outweighs any risk involved in taking their care into their own hands.

“It scares me to think of the potential dangers of self-administering HRT,” Lee said. “But I would rather self-medicate without any physician’s assistance than to detransition.”

The hateful rhetoric of the election, combined with fears about what could happen during Trump’s second term, is also taking a toll on the mental health of many trans Americans.

“Witnessing the backswing of this pendulum has been absolutely soul-crushing,” said Jessica McHegg, a trans woman in Seattle.

McHegg came about eight years ago, in her fifties.

“I thought I was too old, and that there was too much water under the bridge,” she said. “I was a little bit worried about my job. I was worried about my marriage. I was worried about a lot of different things. But, I reached a point where it was just like, ‘I can’t live this fake life anymore.’”

And Seattle, McHegg said, was a “pretty great place to come out.” People were generally very accepting. But now, she is worried for her future, and especially for that of one of her children, who is also trans.

“When you’re a parent that has a transgender child, and then you face the data about suicide, and self-harm, and all these different things, and all of a sudden your kid is in that category, you do not want your child to suffer that,” she said.

“Puberty was devastating to me,” McHegg added. “When we talk about suicidal ideation, and depression, and self-harm, I know exactly what that is. My teenage years were really miserable.”

McHegg stressed that she is in a very privileged position relative to most trans people in the U.S. In addition to living in a supportive city within a supportive state, her wife is Canadian, meaning she and the rest of her family could consider a move out of the country if needed.

But leaving the U.S. would be a last resort.

“I’m determined to fight this one out,” she said. “I’ve been writing email messages to politicians to try to get them to recognize that they need to support us. I’ve donated all the money I can, and continue to donate to organizations like the ACLU and Gender Justice League, but it just feels like a black hole.”

What trans people can do to prepare

Many experts are urging trans people to initiate the process of updating their U.S. passports while current rules—allowing people to change the gender marker on their passport whether or not it matches the gender marker on their proof of citizenship, and without medical documentation—are still in place.

“Make sure you’re very well-connected to your community and know the resources within your community,” Johnson-Weaver added. “You may also want to have that sort of worst-comes-to-worst plan. If you’re in a state where things could really turn bad in terms of having access to care, how can you get your medication?”

In that vein, Williams is working to hold a series of summits on the state of trans health care, and is looking for ways to encourage those in more protective states to support those in states that have already placed restrictions on gender-affirming care, or may do so in the near future.

“What does that look like, to extend our resources to communities and trans folks across the nation that don’t have this privilege, who can’t afford to move to ‘safety’ states?” Williams said.

Beal added that staying connected to your local community is helpful not only in terms of accessing resources, but also to fight what is likely to be a further onslaught of state-level attempts to ban care.

“We’re a marginalized community, and we have to guard our energy and take care of ourselves,” Beal said. “But Audre Lorde’s definition of self-care involves radical community care as well as radical individual self-care. And one of the big things we can do is be involved in local-level politics, because local-level politics filter up, and they can have such a huge impact on individual safety within our own communities.”