Gender-affirming care is not against the law in Pennsylvania. So why have staff at the University of Pittsburgh Medical Center been told they could go to jail for providing it? As of June 30, at UPMC, one of the state’s largest hospital systems, young trans people can no longer be prescribed hormone therapy and puberty blockers, nor are they able to access gender-affirming surgeries. The health care workers who serve trans adolescents across UPMC are angry and heartbroken, two behavioral health therapists at a UPMC center told me this week. If providers continued medical transition care for anyone under 19, Katherine Anderson and Kailey Andrew explained, management said they could be charged with a felony, lose their medical licenses, and serve 10 years in prison. Even if therapists were to refer their clients to providers outside UPMC for gender-affirming care, Anderson said, management claimed that “we could be charged with aiding and abetting a felony.” Hospital workers were also told that if they were prosecuted, UPMC would not defend them, according to the two staffers. But when they repeatedly asked management what law they would be breaking, Anderson said, they were given “really vague answers.”
Some weeks later, on July 25, the White House issued a strange and stomach-churning press release, taking credit for ending what the memo called “child mutilation” in the United States. “For years, politicians have promised to end the barbaric, pseudoscientific practice,” it proclaimed, “but President Trump is the only one who has actually delivered.” Thanks to Trump, the press release said, gender-affirming surgeries for youth were no longer offered at six hospitals and health centers. Trump also took credit for ending gender-affirming care entirely at 15 hospitals and health centers.
By then, nearly 500 hundred UPMC staff had signed an open letter to hospital leadership, enraged that they were being asked to abandon their young trans patients and demanding that the hospital reverse its ban. The UPMC staff letter argued that “directives” such as Trump’s January 28 executive order, “Protecting Children From Chemical and Surgical Mutilation,” as well as the attorney general’s follow-up memo in April, are “aimed at terrorizing medical institutions and providers, but they do not change any existing laws.” Hospital higher-ups may say they are only trying to work within “the law,” but, as the staff letter emphasized, “Gender affirming care is legal in Pennsylvania!”
The same is true of the other states where Trump has claimed credit for ending gender-affirming care at specialized adolescent programs: Arizona, California, Connecticut, Colorado, Illinois, New York, Virginia, Washington, and the District of Columbia. The decisions of hospitals in these states to deny care were not in response to any action by Congress, nor were they required by the recent Supreme Court decision on gender-affirming care, which will make it easier for states with bans to survive future legal challenges, while leaving the door open to further discrimination in health care.
Why, then, in blue states and cities often presumed to be safer for trans kids, where parents might reasonably assume they would find some measure of protection from the Trump regime, are major hospitals refusing care? It is because, contrary to Trump’s self-congratulatory claims, he has not ended gender-affirming care for young people; rather, hospital management, boards, and their legal advisers have ended it for him.
The hospital system, for its part, insisted that its actions were warranted. A spokesperson for UPMC management told The New Republic this week, “UPMC remains steadfast in our commitment to providing exceptional care for all patients.” The Trump administration’s actions, such as “executive branch memos” and “subpoenas,” the spokesperson went on, “have made it abundantly clear that our clinicians can no longer provide certain types of gender-affirming care without risk of criminal prosecution.”
But the UPMC staffers I spoke to said that they believe the hospital has acted prematurely, endangering the young people they care for merely on the basis of threats from the administration. “I’ve had the experience of sitting with a trans teenager at an initial evaluation, and have them look me in the face and say, If I don’t get access to gender-affirming care, I am going to kill myself,” said Kailey Andrew, a behavioral health therapist at UPMC’s Services for Teens at Risk, a program known as STAR, which serves adolescents who are experiencing suicidality, depression, and anxiety. Health care providers have understood for some years that, as multiple researchers have found, hormone therapy can decrease depression and suicidality among young trans people. They took pride, Andrew said, in being able to refer a young person to Adolescent Medicine at UPMC for care, to vouch for the people there, whom they could recommend because they work together closely. Now that the hospital has barred those providers from prescribing gender-affirming treatment, Andrew told me they didn’t know, as a therapist, what their employer expected them to say to a trans teenager in crisis. But then they corrected themself; they knew exactly what kind of response was expected: “Sorry, I don’t know anything about that. It’s illegal for me to share.” In other words, Andrew would be expected to lie. “And I’m not willing to do that,” they said.
There were early indications that hospitals would cave to Trump. Once he issued his anti-trans executive orders in January, major lawsuits followed, with legal experts pointing out—as with all of Trump’s executive orders—that these decrees were not laws; some of them, such as those targeting trans people on the basis of their sex, were even violations of the law. Federal judges have asserted that Trump’s anti-trans military ban “screams animus” and that his ban on gender-affirming care “seems to deny that this population exists, or even has the right to exist.”
Still, as trans kids and advocates had predicted and feared, certain health care providers began complying with Trump’s order in advance. Some trans kids were dropped from care months ago. In February, several thousand community members protested at NYU-Langone, demanding that hospital leadership restore medical transition care for adolescents. In April, Attorney General Pam Bondi announced that the Justice Department would investigate providers of youth gender-affirming care—by misusing a law against female genital mutilation. The Federal Trade Commission tried another tactic, reframing health care such as hormones and puberty blockers—if offered to young trans people—as “fraud,” and threatening their own investigations.
Finally, last week, after months of such threats, the Department of Justice subpoenaed UPMC—one of the “more than twenty” subpoenas the department said it has issued. Pennsylvania Governor Josh Shapiro joined a lawsuit challenging these subpoenas, filed August 1 in the U.S. District Court for the District of Massachusetts, alongside California, Connecticut, the District of Columbia, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Nevada, New Jersey, New Mexico, New York, Rhode Island, and Wisconsin. The lawsuit charges the Trump administration with targeting trans people “relentlessly” and “unlawfully,” refusing them “longstanding, medically necessary, often lifesaving care.” The administration has done this, the lawsuit continues, by intimidating providers with threats of civil and criminal prosecution. It adds, “These threats have no basis in law.” In fact, this intimidation has “coerced” hospitals and health care providers to potentially violate their state’s own antidiscrimination laws.
At UPMC, staff were advised to preserve patient records, among other documents that could be responsive to the subpoena, according to an email obtained by The New Republic. (The UPMC legal staff listed as the senders of this email did not respond to a request to authenticate it before publication.) Staff were also told not to speak about the subpoena. “We are treating the existence of this subpoena as confidential to reduce the potential impact on our patients and employees,” wrote Mark Tamburri, UPMC’s chief legal officer. “In anticipation of potential future investigations and/or litigation, I am directing you to preserve materials beyond the scope of the current subpoena.” Documents to be preserved included “patient records, including identity, clinical indications, diagnoses, assessments, informed consent, patient intake, parent or guardian authorization, disclosure of off-label use, disclosure of potential risks, adverse events, side effects, or medically unfavorable consequences or outcomes,” as well as “diagnosis/ICD codes and use of those codes (e.g., for transsexualism, gender dysphoria, gender incongruence, gender identified disorder, or potential alternatives).”
In aggregate, these records amount to a huge quantity of sensitive information about the health of minors. UPMC Providers for Trans Justice, the emerging group behind the open letter, along with Pittsburgh Healthcare Workers and Scientists, a local group mobilizing for equitable health access, have since pushed back on what they fear is UMPC’s willingness to hand over to the Trump administration minors’ protected health records. “Shapiro is suing Trump and the DOJ partially because of this,” said Katherine Anderson, who works with Kailey Andrew at STAR and also belongs to Providers for Trans Justice. “Why not wait?” The state’s own governor has said, in court filings, that providers have been intimidated out of providing lawful care, in part through these subpoenas; couldn’t his assertion support UPMC in fighting the subpoena? “Why not wait for that lawsuit and see how it goes?” Anderson went on. “Because our governor is actually standing up and doing something!” (The UPMC spokesperson said that the hospital system “will continue to provide essential behavioral health support and other necessary care within the bounds of the law while seeking to protect the confidentiality of the physician/patient relationship.”)
Providers for Trans Justice, Anderson and Andrew told me, plan to put pressure on UPMC higher-ups with a die-in, a direct action where protesters will symbolize with their own bodies the people who may die needlessly as the result of being denied gender-affirming care. The groups have been working with local organizations, such as ACT UP Pittsburgh and TransYOUniting, and members hope more hospitals and health care workers will join them. “This is about trans kids, and our clients, and our community, and us as providers,” Anderson said, but it’s also about “large institutions like UPMC caving in to fascism.” If major health care institutions are willing to let “baseless threats” end this care for a small population that’s been politically marginalized, Anderson continued, and then “hand over all of that vulnerable population’s medical data without a fight, then none of us are safe.” For now, that means health care workers must protect their patients and clients not only from Trump but from the leadership and the boards of the hospitals that ostensibly care for them.