Yes, That Big Anti-Trans Ruling Is Terrible. There’s Also a Bigger Problem.

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On Wednesday, the Supreme Court issued its opinion in one of the biggest trans rights cases of the last decade. States, the court ruled, can ban gender-affirming care for minors. It was a stunning decision and a major setback for trans rights, but it was hardly a surprise. After what felt like many years of forward motion, the trans rights movement has been weathering extreme blowback—much of it aimed at young people.

In a nation as polarized as the United States, and with such a robust reactionary right, there was likely no way to entirely avoid the toxic politicization of trans health care. But for those of us who support that care, our defenses may have been stronger with a more nuanced approach—and if our country had better health care to begin with. As we chart a way forward in a country that is in a period of right-wing retrenchment and abject hostility toward trans people, it’s worth reminding Americans writ large that this issue isn’t just about a vulnerable minority group (although of course it is about a vulnerable minority group). It’s about a health care system that has failed not just trans people, but most of us, and a right-wing movement full of blatant hypocrites who claim they want to protect trans kids while undermining the only way to do just that.

In the past decade, trans people have seen remarkable progress in both rights and visibility. In 2014, trans actress Laverne Cox struck a glamorous pose on the cover of Time magazine under the headline “The Transgender Tipping Point.” In 2016, the NCAA boycotted North Carolina after the state passed a “bathroom bill” that would have barred trans people from using the bathroom that matched their gender identity; the NBA moved its All-Star Game out of the state after a law pulled antidiscrimination protections from LGBTQ+ people. Public opinion was also increasingly supportive of trans rights. By 2022, most Americans opposed “bathroom bills”; nearly two-thirds said that trans people should be legally protected from discrimination in housing, employment, and public space. Fewer than half of Americans supported banning gender-affirming care for transgender children and teens.

When Donald Trump came back into office, he retook aim at a familiar litany of foes: immigrants, criminals, liberals. But transgender people—and especially trans young people—moved higher up the Trump target list, along with their parents, and the doctors who help them transition. Trump’s attacks on what he calls “transgender lunacy” have included kicking trans people out of the military, refusing to issue passports that indicate a nonbinary gender, pulling federal funds from schools that conservatives say teach “gender ideology,” and banning trans athletes from playing on the teams that match their gender identity.

And it’s not just Trump. According to a February 2025 Pew survey, a majority of Americans, including more than a third of Democrats and almost 80 percent of Republicans, say that it should be illegal for health care professionals to help minors transition. Close to 50 percent believe trans people should have to use the bathrooms consistent with their birth sex, two-thirds say trans athletes should have to compete on the teams that match their sex at birth, and support for nondiscrimination laws that cover trans people has slipped from 64 percent to 56 percent. Republicans are more hostile to trans rights than Democrats. But across every measure, Democratic support for trans rights has slipped, too. In 2020, gender-affirming care for minors was legal across the nation. Now, 26 states have banned or restricted it, and the Supreme Court has said those laws can largely stand.

A new podcast from the New York Times aims to explain how we got here. The Protocol tells the story of how a Dutch clinic attempted to develop a standardized practice for treating transgender youth, and how that protocol was interpreted, implemented, challenged, and changed in an American context—and how the anti-trans movement grew so quickly and so virulently in response to an uptick in transgender minors getting treatment. The podcast itself has been controversial. Before it was even released, some trans rights advocates denounced it on social media, arguing that the reporter was biased against trans rights and objecting to the podcast “platforming” opponents of trans youth medicine. After it came out, opponents of trans rights also accused the reporter of bias, and argued that the podcast paid insufficient attention to people who transitioned then changed their minds and reverted to their birth gender. One of the subjects of the podcast and a related story in the Times says that she was misrepresented.

It’s easy to get hung up on the controversies around the podcast. But it makes clear that the gaps in trans health care in the U.S.—and the reasons why the attempted implementation of the Dutch protocol went so sideways—bear virtually zero relationship to the right-wing story of nefarious doctors and gender activists with predatory agendas. Instead, it’s a far more mundane and familiar story: A fractured and badly deficient American health care system made for fractured and deficient trans health care. And as supporters of trans rights grapple with conservative attacks that have gained stunning speed and force, we need to face that reality, too.

When it comes to trans rights in the U.S., two issues seem to be the most galvanizing on right and left alike: trans athletes competing in women’s sports, and trans and gender-nonconforming young people being given puberty blockers and sometimes hormones or surgeries. It’s the second of these topics that The Protocol covers.

Puberty blockers are medications that delay puberty, allowing trans people to more seamlessly transition and preventing or delaying the onset of secondary sex characteristics that can feel starkly out of line with a person’s gender identity. But these medications by definition have to be given to young people—those who have not yet gone through puberty. There are not definitive numbers on how many young people have used blockers or hormones, but studies indicate the numbers are small. One recent study in JAMA looked at the roughly 5 million teenagers who use private health insurance and found that fewer than 0.1 percent are trans and used puberty blockers or hormones. An investigation in Reuters found that, while more than 42,000 patients ages 6 to 17 were diagnosed with gender dysphoria in 2021, just 1,390 of them received puberty blockers, while 4,231 received hormone therapy.

The Dutch protocol, as it is known, was developed at a Dutch gender clinic, and involves significant mental health screening and support before puberty blockers and then hormones are given to trans young people. The requirements are fairly high: Gender dysphoria must be persistent and long-felt, not something that developed in response to a trauma or impending puberty; patients with psychological issues like bipolar disorder or neurodevelopmental disorders like autism were generally not considered good candidates; patients must have been under the consistent and monthslong care of a trained therapist and would continue getting therapy throughout their treatment; patients must have the support of their families. Within those constraints, the trans patients who received care in the Dutch clinic generally did well, both with treatment and then as they went out into the world as adults.

As the number of trans-identifying young people grew in the U.S., many providers tried to implement the Dutch protocol here. But, if you live in the U.S., you might already be able to see where they hit roadblocks. High-quality mental health care that is covered by insurance is scarce in the U.S., let alone care by a therapist or psychologist trained to work with trans kids. The Netherlands is a fairly small country; the U.S. is enormous and sprawling, making regular appointments at one of the nation’s very few gender clinics impossible for many families. And America’s conservatism and religiosity has always meant that a great many families are hostile to gay, trans, or gender-nonconforming people, even when those people are their own children.

Plus, of course, politics. The American right spent decades fighting against feminist efforts to loosen the strictures of traditional gender roles, and then against gay rights. It’s entirely predictable that trans rights are now squarely in their crosshairs. That politicization of trans rights, and especially of youth gender medicine, has had a corrosive effect on nearly all aspects of the issue, from the care itself to the conversations about it.

Justifiably scared of this care being taken away, some trans rights activists have found themselves in a defensive crouch, unwilling to admit that there are problems at all and launching coordinated campaigns against anyone—even those who support trans rights—who suggests otherwise. In some factions of the trans rights movement, there is a consensus that it’s morally wrong to “platform” people who oppose providing trans health care for minors, even in the kind of journalistic contexts that generally require hearing out the opposition. And the movement’s rhetoric has grown increasingly maximal, perhaps best summed up by the now-familiar question “Would you rather have a dead son or a live daughter?”—a suggestion that, for most trans young people, the choice is between transition or suicide. This question is an important one, given the elevated rates of suicidality among trans people. But it can also be used as a cudgel to shut down conversation, concern, and questions, especially from parents struggling to guide their children through life-altering decisions before those children’s brains and their decisionmaking capacities have fully developed. And when enough people feel shamed into silence and emotionally browbeaten into shutting down, things boil over.

The Dutch model also met some resistance in the U.S., with our more fractured health care system and our more individualistic culture. Why, some doctors asked, should young people have to jump through all of these hoops if they are sure of what they want to do with their bodies and their lives? Why does a kid have to go to a year of therapy when they’re clear they want puberty blockers? Why should, for example, autism or mental illness be an extra barrier—surely someone can be autistic and transgender, or bipolar and transgender. As more trans adults spoke out about their infuriating experiences with health care—or, more accurately, with not being able to get the care they needed—a general skepticism of “gatekeepers” grew in the trans rights movement. And the sense that providers should listen to what patients want and not gatekeep care infused the intra-movement debate about care for trans young people, leading many clinicians to conclude that their task was service provision, not gatekeeping.

These debates were already playing out within the trans health care community when, during the Biden administration, the political attacks ramped up. And had health care for trans children not become an inflammatory political issue, I suspect that ultimately, that care would have improved, because providers could have spoken more candidly with each other about various concerns and challenges, and addressed gaps openly. Instead, political battles grew pitched and ugly, and the chief antagonists were not people with genuine concerns for trans kids, but people who believe that transgenderism is a mental illness and gender-nonconforming kids should be taught to conform to their birth gender. For defenders of trans youth medicine, this made even well-meaning questions about that care potentially dangerous. Among activists, the argument became that the science was settled and this care was safe.

Except, while there are now decades of research and findings on adults who transition, there is far less research on trans young people and what happens in the longer term with puberty blockers, hormones, and surgeries. Many opponents and skeptics of trans youth medicine say we need more research, and they’re right—except then they push laws banning trans youth health care, which makes research impossible. “We need more research” has become a conservative pretext for simply shutting down health care access for trans young people. And as a result, it’s become awfully hard for people who actually want more research into trans youth medicine to adequately advocate for it. Any nuance in this space is seized upon by the right to attack trans people and those who provide them care, and objected to by the trans-activist left who see it was a potential weapon to be turned against what they say is a simple and urgent cause about which there are not two sides.

There are some lessons here, if we care to learn them. The first is that demands for ideological fealty do not pair well with the realities of medical progress and research in novel areas of science and health care, especially where that care also touches on a whole series of cultural debates and questions as fundamental as who a person is on the inside. Activists have one job; researchers and medical professionals have another (although activists concerned with changing minds, or even with introducing the public to what is for many people a new concept, would probably be better served by addressing legitimate concerns rather than shouting down opponents or engaging in emotional manipulation).

The second is that issues like trans health care, which is focused on a small and vulnerable community, can be microcosms of much bigger problems, and should be situated in context. Why don’t all trans kids and teens get the kind of robust mental health care they need, and why aren’t they able to see doctors and specialists as often as is necessary to guide them through a physically and emotionally complex journey? Because virtually no one in America gets adequate time with physicians and specialists and therapists. That doesn’t mean we should accept this as the status quo. It does mean that the conservative story of slipshod care and predatory doctors isn’t true—and that a push for better trans health care means pushing for better health care across the board, a win for just about everyone.

Finally—and this one is directed at the people who don’t generally oppose trans rights but do perhaps think we should ban trans youth medicine—it’s nearly impossible to learn more about a treatment if we ban it wholesale, because you can’t study something you can’t do. It’s also awfully hard to provide high-quality, high-touch care if providers are few and far between, health workers can’t provide care in half of U.S. states, and patients have to travel long distances. If the ideal really is consistent check-ins with doctors, steady therapy with qualified professionals, and the ability to adjust and calibrate care to an individual’s specific needs as their body changes, then we need clinicians and therapists working in all 50 states.

Making this care illegal in entire swaths of the American South and middle also means that health care providers working with trans young people in more liberal states become far more overloaded, and are working with patients who may be coming in sporadically from out of state. That might work for a one-off procedure, which is what abortion clinics, for example, currently struggle with. But it’s far less optimal for yearslong care, and especially care that involves developing bodies and fluctuating hormones and evolving brains and potentially changing minds.

We don’t have as much high-quality research into trans youth health care as just about anyone would like. What we have suggests that the available treatments are generally safe but do have some serious potential side effects, and that rates of regret and detransition do exist but are very low. The landscape, though, is changing—more young people are identifying as trans and seeking gender-affirming care, and the profiles of those young people are different (more of them are experiencing gender dysphoria as a recent phenomenon rather than a lifelong struggle; more of them are nonbinary or were born female and are identifying as male). If we want clearer answers as to why these changes are occurring, and better protocols for treatment, then bans are the worst way to address concerns. This care, and research into it, needs more resources, not more fear.

There are many bad actors in the broader conversation around trans rights, and conservatives have generally proven that they will exploit any vulnerability to yank care away from those who need it. But a fear of right-wing reaction shouldn’t make the rest of us—supporters of trans rights, but also those who question some of the tactics employed by trans rights activists, who don’t see the science as settled, and who genuinely do want to improve outcomes, especially for young people—shut down genuine curiosity or sidestep genuine problems.

Many of the issues with trans youth medicine in America are less about the “trans youth” aspect and more about American medicine writ large: its shoddiness, its expense, its patchwork nature, its insufficiency, and now across so many kinds of treatment from abortion to vaccines, its politicization. Whatever legitimate research gaps and real problems with this care exist are only made worse by bans. And instead of staying stuck in the weeds of who should be “deplatformed” or what terminology signals what side of this issue (that supposedly doesn’t have sides) you are on, advocates for trans rights should stand squarely on the side of curiosity, empathy, and demands for more and better research and the highest-quality care—and emphasize that those banning the care are the ones making better research, more information, and meticulous care impossible.