PHILADELPHIA -- A few weeks after Donald Trump won the presidential election, Wesley Hiester and his mom went to see Hiester’s doctor to ask about stockpiling a larger supply of testosterone.

The 17-year-old, who started hormone therapy when he was a high school freshman, was concerned that there could be restrictions placed on the gender-affirming treatments he received. He wanted to be prepared.

This week, Trump issued an order barring federal funding of gender-affirming care for people under the age of 19. The executive order directs agencies to cease grants and other funding that could be used for hormone therapy, puberty blockers, or surgeries for transgender children. It also directs the U.S. Department of Health and Human Services (HHS) to review the terms of publicly funded coverage under Medicare, Medicaid, and the Affordable Care Act to curtail gender-affirming care.

The order, widely expected to be challenged in court, could prevent those recipients from being able to receive the treatments and have a chilling effect on providers willing to offer gender-affirming care, doctors and legal experts said.

“Obviously, going into Trump’s presidency we all knew what his agenda was,” said Hiester, who lives in West Chester. “I wasn’t shocked but the worst is he raised the age to 19, so I have another year to worry about this. I’m a senior. I’m committed to college. I should be enjoying every single moment but now, first with the election and now this, it’s really hard to focus on the good things.”

Hiester has private health insurance and believes that for now, he will still have access to his hormone therapy, but he and others in the transgender community are concerned about a cascading effect that could threaten access, depending on how the order is interpreted.

And the larger impact, Hiester and others have stressed, is the mental and emotional toll as Trump’s directives pile up.

One of Trump’s most vocal promises on the campaign trail was to end gender-affirming care. On his first day in the White House, he declared his administration would recognize only two genders. And a slew of executive orders have targeted transgender people, including a directive that the military adopt a policy that being transgender is incompatible with “high standards for troop readiness,” and an order dropped Thursday banning “radical gender ideology,” in schools.

The order about minor care, titled “Protecting Children From Chemical and Surgical Mutilation,” describes widely medically approved transgender care in inflammatory and misleading language, claiming children are being “maimed” and “sterilized.”

While the order suggests this medical treatment is routine, very few minors undergo surgery to affirm gender and a small percentage of the adolescent population seeks gender therapies. Gender-affirming care for children and adolescents has been deemed medically appropriate by the American Academy of Pediatrics and other major medical and mental health organizations. Research shows young people with gender dysphoria suffer higher rates of suicide, self-harm, depression, and anxiety.

Gender-affirming care broadly refers to medical services intended for people whose gender identity does not match the gender they were assigned at birth. Care could range from voice coaching and hair removal to hormone therapy and surgery. Trump’s order specifically applies to chemical (such as hormonal treatments) and surgical therapies.

Conservative lawmakers’ defense of gender-affirming care bans often argue some therapies are irreversible and could come with side effects such as the risk of fertility loss. But researchers and medical professionals say more research needs to be done to confirm the accuracy of any side effects, and LGBTQ advocates note that de-transitioning is extremely rare.

“His order has the potential of making gender-affirming care very difficult, if not impossible, to get even for adults and more specifically for adults who are financially or otherwise already underserved and already marginalized,” said Shanin Gross, a family medicine doctor in South Jersey who specializes in gender-affirming care.

How the order could impact care at CHOP and other clinics

In Pennsylvania and New Jersey, clinics, hospitals, and organizations that serve transgender and nonbinary people urged calm. The action is likely to face challenges while they are trying to sort out what its implementation could mean for their work.

A primary concern is that medical institutions that receive federal funding for research or education grants that also provide care to transgender youth could lose funding.

Gross, a 55-year-old doctor from Cherry Hill, worries that the order’s restrictions on Medicaid and Medicare could discourage doctors from providing gender-related care through these government-funded programs providing health coverage for low-income children and families, people with disabilities, and seniors.

Gross also fears the order could trigger sanctions that would prevent a doctor from participating in Medicaid or Medicare.

“I think that the goal behind the whole executive order and the intentionally broad and vague way it is written is to frighten as many health systems and individual providers as possible into thinking that they will lose funding or otherwise be unable to conduct business,” Gross said. “And the implication of the government officials with no medical training controlling what medical treatments we are allowed to have is terrifying and something we all should want to avoid.”

The order could further restrict access to treatments that can already be difficult to get for minors in the U.S. Twenty-six states have restricted youth access to gender-affirming care, which remains legal in Pennsylvania and New Jersey.

“Clearly the intent of the executive order is to create a climate of fear and anxiety that will result in care deprivation,” said Harper Seldin, an attorney with the ACLU.

Sultan Shakir, president and executive officer of the Mazzoni Center — Philadelphia’s biggest LGBTQ health agency — denounced the action, stressing that “transgender people of all ages” are “entitled to the care and opportunities that others take for granted to live lives recognized as their full selves.”

The Center City nonprofit provides medical care for transgender individuals including hormone therapy.

The Children’s Hospital of Philadelphia runs one of the nation’s largest clinics providing medical care and mental health support for transgender and gender nonbinary children and teens and their families. The hospital’s Gender & Sexuality Development Program was founded in 2014.

In 2021, more than 800 new families sought care — a record surge from the prior year when between 250 to 350 families received services, according to CHOP.

Trump’s order directs the head of HHS to take all appropriate steps to end gender-affirming care, including scrutinizing Medicare or Medicaid “conditions of participation or conditions for coverage” and “clinical abuse or inappropriate use” of state Medicaid programs.

It’s not clear what the impact on CHOP could be.

CHOP said in a statement Thursday that its “top priority is always the safety and well-being of the patient families we treat, ensuring that each child has a chance for a healthy future, while complying with applicable laws and directives. We look forward to continuing to work closely with our partners in government to make sure that the needs of children and their families come first.”

‘The third option is to run away’

For several transgender individuals and their parents interviewed, the worry is that therapies and support groups they depend on could shutter.

Joanne, 52, of Center City, is concerned that her daughter, who has been on a two-year waitlist for surgery, could have to wait even longer. The Inquirer isn’t printing Joanne’s last name to protect her daughter, who she fears will face public backlash.

The mother said she’s looked into surgery in Thailand but worries about the language barrier. As her daughter starts looking at schools, she’s urged her to apply to universities in Canada.

“I’m at the point where I don’t think we can beat them anymore so I don’t know how much I can try, and I’m certainly not going to join them, so the third option is to run away,” she said.

Gender-affirming care is expensive, something parents who’ve gone through the process worried about this week.

Dawn Bowman, whose 20-year-old son is transgender, said her family sold a life insurance policy to help pay for therapies when he was in his teens.

“At a point, I realized this is a life or death thing,” she said. “What really gets lost in this discussion is that when these kids go through the wrong puberty, they self-harm. It’s OK to not understand things but to demonize people because you don’t understand them, and say they’re you’re to help them, you’re actually hurting them.”

As Trump ends just his second week in office, Hiester is trying to focus on school, playing tennis, and his job as a lifeguard. In the fall, he’ll head to college in Washington, D.C., where he wants to study education to become a high school teacher. He’s inspired by teachers who supported him over a tough last four years.

“The larger impact of all this, is just how much hatred there is…that can have such an effect on, especially, younger trans people,” Hiester said. “People who are just trying to live their lives and be a kid.”

Staff Writer Harold Brubaker contributed to this article.

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