First, do no harm—unless you're intersex or trans

Since Trump took office, several hospitals rushed to cancel patients’ appointments in response to Trump’s Executive Order aimed at gender-affirming care. Reports emerged of adolescents stripped of essential care, such as puberty-pausing medication and hormone therapy needed to treat their gender dysphoria. Many of these young people had been receiving this care for years; others may have waited for months or traveled across state lines to see a provider. While a federal court has blocked implementation of the order, some hospitals are still choosing to halt the provision of consensual and evidence-based gender-affirming care for patients under age 19.

These hospitals’ choices are hurting their patients. And they are, to be clear, choices. While the Executive Order is by no means harmless, it does not impose new obligations on hospitals on its own. Executive Orders express the President’s priorities and expectations for how agencies will develop and enforce regulations, but they cannot change existing laws or court decisions. Hospitals abandoning their transgender patients are engaging in overly cautious preemptive compliance, throwing their hands up and acting as if they’re already tied.

Many of these same hospitals had a very different response when intersex advocates called for a halt to non-consensual surgeries on intersex infants and children. Institutions including NYU Langone, Children’s Hospital Colorado, and Seattle Children’s Hospital stopped providing necessary care to consenting transgender patients in a matter of days. Still, they’ve spent decades refusing to stop “normalizing” intersex infants’ bodies without their consent.

Intersex—the “I” in LGBTQI—refers to people born with a wide range of innate variations in their physical sex traits such as chromosomes, genitals, gonads, and hormones. There are dozens of known intersex variations, and at least 2% of the population has one. You wouldn’t know this by looking at scrubbed government websites, with references to intersex people along with transgender people removed. People may discover they are intersex at different times throughout their lives. Some women assigned female at birth discover their XY chromosomes and internal testes closer to adolescence. Other variations are noticeable at birth, particularly if they cause differences in genital appearance. Infants and children with these differences are at particular risk for another kind of erasure—surgical.

When the Trump administration uses the fear-mongering phrase “child sexual mutilation,” it deliberately mischaracterizes the affirming care that transgender adolescents seek to meet their needs. Ironically, this phrase does describe surgeries performed on intersex infants who cannot consent. Often called “intersex genital mutilation” (IGM), these procedures forcibly conform an infant’s body to societal expectations of male and female bodies, disregarding the individual’s right to decide how their body will look, feel, and function. Pressured parents agree to these procedures without understanding the long-term implications.

These procedures could not be further from the consensual gender-affirming care that trans adolescents seek. Surgical gender-affirming care is rare for minors; medical interventions usually involve puberty-pausing medications or gender-affirming hormones. Most importantly, minors who access gender-affirming care do so after periods of significant reflection on their identities and the care they’re seeking. These decisions come with support from medical and behavioral healthcare providers and their families. The regret rate for gender-affirming care remains very low. It’s substantially lower than the regret rate for knee replacement and many other forms of healthcare, and even the rate of regretting having children.

Intersex advocates first protested against IGM in 1996, but the practice continues in plain sight. In recent studies, surgeons at New York Presbyterian/Weill Cornell, Children’s Hospital Colorado, Lurie Children’s Hospital, and the Children’s Hospital of Philadelphia rate the appearance of intersex infants’ genitals before and after they operate, and ask whether parents are more or less depressed afterward. The University of Michigan reported removing intersex infants’ testes to reinforce a female sex assignment. At the same time, co-authors at Seattle Children’s Hospital pushed for an exception to Washington’s sterilization law to allow them to do the same. When a new generation of advocates protested at New York Presbyterian/Weill Cornell and Lurie Children’s Hospital, the former was unresponsive. Lurie resisted for years before announcing in 2020 that it would no longer perform most forms of IGM, leaving loopholes for some to continue.

These hospitals’ policies remained unchanged for decades. Yet each of them swiftly abandoned or began “reviewing” their gender-affirming care practices in light of an unenforceable Executive Order. Among hospitals that faced protests over curtailing care for trans patients, some agreed to resume gender-affirming services as courts blocked agencies from implementing the Executive Order. Lurie, however, kept its “pause” in place even then. New York Presbyterian/Weill Cornell removed references to gender-affirming care from its website—even striking puberty-pausing medication from its list of services—but still promotes surgery to reduce “enlarged” clitorises on intersex six-month-olds. (So does NYU Langone, which has also failed to clarify its gender-affirming care policy following initial appointment cancellations.) These hospitals and their providers have disregarded their ethical responsibility to “do no harm” and have instead denied both intersex and transgender patients the right to make decisions about their bodies.

The State Department, the American Academy of Family Physicians, and the United Nations Human Rights Council have spoken out against IGM in recent years. Taking away self-determination through non-consensual surgery causes irreversible harm—survivors of IGM experience medical mistrust, PTSD, and increased suicidality alongside the impacts on their bodies. Days before Trump took office, the Department of Health and Human Services released a report criticizing the practice. The agency has since scrubbed it from its website.

Amid uncertainty and upheaval, hospitals still must honor their ethical obligation to do what is best for their patients. That means committing to provide care for transgender patients and prohibiting non-consensual surgeries on intersex infants. To fulfill their oath to do no harm, individual providers have bravely committed to going to jail before they stop providing lifesaving gender-affirming care. Citing that same oath, former U.S. Surgeons-General urged against operating on intersex children until they can decide. Now, it is up to hospitals to champion consensual, affirming healthcare and defend their patients from intrusions on their autonomy. The failure of these institutions to act by these ethical principles will continue to have dire consequences for trans and intersex youth.