175. What is Gender-Affirming Care?

Snarky Opener (0:00)

Interesting how cisgender people are trying to regulate queer bodies, even though they're the ones seeking out gender-affirming care the most.

Episode Introduction (0:26)

Hello, my LGBTQuties, and welcome back to another episode of A Jaded Gay. I'm Rob Loveless, and today I am a non-jaded gay because my new book, Besties in Crime, is officially out in the world.

And I swear that wasn't planned to have it be released the same day as my podcast episode, but what a happy surprise.

Now, I can't remember if I plugged this before, but Besties in Crime is a queer crime caper published by NineStar Press.

Two down on their luck best friends, one divorce, and a very drunken night ending in accidental arson and a crash course in the criminal world.

It follows Jay and Gia, childhood best friends who drifted apart until the latter's messy divorce brings them back together. I know, a girl and her gay. A trope as old as time.

But what's meant to be healing quickly spirals out of control when they drunkenly burn Gia's house down... with her soon-to-be ex inside. Oops.

Fleeing the scene, Jay and Gia are confronted by mobsters claiming Gia's ex owes them money.

And what follows is a runaway disaster of car chases, gunfights, burlesque shows, bank robberies, and a final showdown with the FBI.

Think Will & Grace-inspired shenanigans meets Schitt's Creek-style dark humor, with the duo trying to outsmart the crooks one pop culture reference at a time.

And here's a podcast exclusive. The characters Jay and Gia are basically me and my friend Sara. Shocker, right? You might remember her most recently from January's bonus episode.

Anyway, we both had a tough 2019 where she separated from her husband, and I was there to help her get through it.

And then a few months into her separation, I had a fling that lasted a few months, but when he broke up with me, I had a really tough time.

So, the beginning of the book very much encapsulates that time in our lives, and some of the dialogue and stories about exes are entirely true.

Like when my ex took me out for my birthday dinner and wouldn't look at me the entire time, and then broke up with me a week later. Yeah. But I didn't start writing Besties in Crime until late 2020.

In like July 2020, I finished writing my last book, Eleftheria, so I had worked on cleaning that up. But then one day, during the pandemic, I was listening to an episode of Wine & Crime, which Sara and I both love.

And in the episode, they were either talking about friends who had committed a crime together or burned something down. I can't quite remember.

But I believe the hosts were laughing about it because the perpetrators did a terrible job and incriminated themselves, like so bad. It was funny.

And as I was listening to it, I thought to myself, I wonder if Sara and I could get away with something like that. And then the plot hit me. Me and Sara burn down a house and get involved with criminals.

So, I called her immediately and told her, and as I was talking to her, I kind of fleshed it out like it'll be about your divorce, and we accidentally burn your house down, and then somehow criminals come after us, but why?

And I just kind of wrote it from there. So, I'm very excited that's out in the world now. I've included the link to it in the show notes, so I'd appreciate it if you buy a copy and give it a read.

Hope you all enjoy it. I think it'll give you a good laugh.

And quick disclaimer: while the characters are based on me and Sara, no exes were physically harmed in the making of this book. Emotionally, though, results may vary.

Gender-Affirming Care (3:00)

Anyway, shifting gears entirely today, we are diving into a more controversial topic, and that's gender-affirming care.

Now this came under attack a lot last year by the Trump administration, who was claiming that the LGBTQ+ community was pushing transgender for everybody.

Even though there are plenty of cisgender people in his administration who receive more gender-affirming care than transgender people.

But that goes to show that there's this misconception that gender-affirming care is synonymous with transitioning, which it's not.

So, I wanted to take a look at what it actually is from a factual standpoint, not opinion or political based. So, we will be diving into it. But before we do, tarot time.

Tarot (3:38)

So, the card for this episode is the Four of Cups in reverse. Now, Cups is tied to the element of water. It's feminine energy, so it's reminding us to meditate and reflect.

And Cups is tied to our emotions, which we can think of as flowing freely like water. In numerology, four is tied to structure and stability.

And when we draw the Four of Cups in reverse, it's telling us that we're in a period of introspection and withdrawal.

And while being withdrawn is sometimes viewed as a negative thing, this card is telling us to be in this space and start reintegrating when we feel ready to.

We should appreciate this time we're in so we can check in with our inner self to make sure that the things we're saying yes to are a good fit for us.

We may also feel uninspired, disillusioned, or disappointed with the world around us, and while it may be easier to hide from those things, we can't avoid them forever.

While it's okay to withdraw from them temporarily, we need to remember that ignoring those things won't fix them. And we can't always wait for change, because sometimes change comes from within.

What is Gender-Affirming Care? (4:28)

So, with that in mind, let's kick it off with a vocabulary lesson.

The World Health Organization defines gender-affirming care as health care that can include any single or combination of a number of social, psychological, behavioral, or medical interventions, including hormonal treatment or surgery, that are designed to support and affirm an individual's gender identity.

Now note how that is the definition for gender-affirming care, and that it can include hormonal treatment or surgery.

However, gender-affirming care does not equal surgery, and it's also not always synonymous with gender-affirming surgery.

So, let's break that down even further with some common examples of gender-affirming care.

From a social standpoint, it can include changing appearance via hairstyles and clothing, using makeup, choosing a name or pronouns, and updating legal documents like IDs or birth certificates.

Psychologically speaking, gender-affirming care can involve going to counseling or therapy to explore identity, cope with dysphoria, and navigating family and social challenges.

And gender-affirming care at the medical level can include getting laser hair removal, receiving hormone therapy, whether that be estrogen or testosterone, taking puberty blockers, and undergoing surgery.

And we'll get into some of those medical avenues in a bit. But as you can see, gender-affirming care is a spectrum, and can range from simply wearing a piece of clothing to undergoing surgery.

It's also individualized and does not equal one thing.

So, when you hear all these politicians condemning gender-affirming care, do you know what they're actually referencing? Do they actually know what they're referencing?

Because gender-affirming care is not always treatment for transgender people. As you can see, some of those are pretty common things that most of us may have done at some point in our lives.

In fact, Dr. Theo Shall, Assistant Professor of Health Policy and Management at the University of Massachusetts Amherst, notes that some common examples of gender-affirming care among cisgender people are hair plugs, taking testosterone for weight lifting, and even surgeries like jaw recontouring that help cisgender men feel more masculine.

And with that in mind, I think you can think of some other everyday examples that are considered gender-affirming care, like a cisgender man treating his gynecomastia with breast reduction surgery, or a cisgender woman getting lip filler in a boob job, or getting rhinoplasty, or taking hormone replacement therapy for menopause, or wearing makeup wigs or hair extensions, or even using gendered deodorant or body wash that smells a certain way.

The thing with gender-affirming care is that it is about affirming whatever gender you identify with, whether that matches your biological gender or not.

So, if you're a cisgender man who takes creatine because you want to build more muscles and feel more masculine, that's gender-affirming care.

If you're a cisgender woman who wants to contour her face with makeup, that's gender-affirming care.

And if you're a transgender man who begins using he/him pronouns, that's gender-affirming care, too.

Again, it encompasses a spectrum of things, and despite what politicians may say, this isn't a new thing.

The History of Gender-Affirming Care (7:02)

Now, in the context of the examples we talked about, I think it's safe to say that gender-affirming care has been around forever. Think about it.

Throughout history, we've seen shifting trends that reinforce what was considered feminine or masculine at the time. Like women wearing corsets in the Renaissance era, or men wearing heels and makeup in the 17th century.

And plot twist that was considered masculine and a status symbol at the time.

But in the more literal sense of gender-affirming care, its earliest roots go back to the 1920s in Germany, when Magnus Hirschfield, a physician and sexologist, and other doctors, conducted formal studies and treatment of gender dysphoria.

And according to the American Psychiatry Association, gender dysphoria is a psychiatric diagnosis that refers to the psychological distress that results from an incongruence between one's sex assigned at birth and one's gender identity.

In other words, this occurs when people strongly believe that their gender does not match the sex they were assigned at birth.

And by distress, they mean anxiety, depression, anger, or low self-esteem, feeling trapped in the wrong body, isolating socially, or having increased suicidal ideation.

And a formal diagnosis requires this type of distress to last at least six months and impair daily functioning.

But back to Hirschfield, according to Harvard's School of Public Health, he dedicated his life to understanding human sexuality and advocated for the rights of marginalized communities, including the LGBTQ+ population.

And he and his colleagues were among the first to recognize that gender identity is separate from sexual orientation.

According to Dr. Elena Mancini, Dora Richter was the first known trans woman to undergo male-to-female genital surgery under Hirschfeld's care.

In 1922, she underwent a surgery that removed the testicles, and in 1931, she underwent a penectomy followed by vaginoplasty months later.

In May 1933, the Nazis raided Hirschfeld's Institute and then began their persecution of transgender people.

However, post-World War II, Hirschfield's ideas inspired new generations of researchers, and in the United States, a new wave of medical professionals began exploring the unique needs of transgender individuals.

For example, Dr. Elmer Belt was a Los Angeles-based urologist and is considered the first US surgeon to perform gender-affirming surgeries in the 1950s, although he did so in secrecy.

In 1966, Johns Hopkins Gender Clinic opened and provided comprehensive care for transgender people, including counseling, hormone therapy, and gender-affirming surgeries.

The clinic also implemented the "Real-Life Test," which required patients to live in their preferred gender role for an extended period of time before being considered for gender-affirming surgery.

However, in 1979, Janice Raymond, an out lesbian and trans exclusionary radical feminist, or a TERF, published The Transsexual Empire, which argued against the existence of trans people.

And soon after, Dr. Paul McHugh, the recently appointed director of psychiatry at Johns Hopkins, decided to close the Gender Clinic.

Then, in the early 1980s, the Reagan administration determined that gender-affirming care was experimental and therefore not covered by federal insurance programs such as Medicaid and Medicare.

And this created a catch-22 since gender-affirming medical care cannot be covered by insurance, since it was considered experimental, despite the first research being conducted approximately sixty years prior.

But further research couldn't be conducted because of a lack of federal funding. Now, fast forward to 2010, the Affordable Care Act expanded protections for gender-affirming care.

And in 2016, under the Obama administration, the federal government removed the experimental designation.

However, in June 2020, the Trump administration reversed Obama-era protections that prohibited discrimination in health care based on gender identity.

And obviously, there's more present-day politics to discuss regarding gender-affirming care. But as you can see, it's certainly not a new concept.

Puberty Blockers (10:28)

Now, two of the more common forms of medical based gender-affirming care that don't involve therapy are puberty blockers and hormone therapy. So, diving into those a bit deeper.

Puberty blockers are medications that are used to delay the changes of puberty in transgender and gender diverse youth who have started puberty.

And they've been used since the early 1980s to treat early onset puberty in young children.

Then, in the 1990s, they started being used in transgender adolescents to help prevent the unwanted development of masculinizing or feminizing physical changes that occur during puberty.

The most commonly used puberty blockers are gonadotropin-releasing hormone agonists or GnRH, which temporarily stops the body from making sex hormones, including testosterone and estrogen.

Now, GnRH analogue medicine is prescribed and given, and monitored by a healthcare professional who has expertise in this group of medicines.

And it's typically given as a shot, either monthly or every three to six months, and regular blood tests are needed throughout the use of the medication to check the medicine's effectiveness.

For people assigned male at birth, puberty blockers slow the growth of facial and body hair, prevent voice deepening, and limit the growth of the penis, scrotum, and testicles.

And for people assigned female at birth, they limit or stop breast development and stop menstruation. Again, this is temporary and doesn't cause permanent physical changes.

Instead, it just pauses puberty, and once someone stops taking GnRH analogues, puberty starts up for them again.

Now that being said, that doesn't mean there aren't side effects, and some of the possible short-term ones include swelling at the site of the shot, weight gain, hot flashes, headaches, and mood changes.

There could also be longer-term side effects on growth spurts, bone growth, bone density, or fertility, depending on when the medicine is started.

And for that reason, those who take GnRH analogues typically have their height checked every few months. Yearly bone density and bone age tests may also be advised.

Now, the Mayo Clinic states that puberty typically begins around age 10 or 11, although it can start later or earlier.

But that being said, puberty blockers are not recommended for children who have not started puberty. And I would just like to add a quick anecdote.

One of my friends, who is a straight cisgender female, told me that her parents gave her puberty blockers as a kid because they thought she was developing breasts too early. So just keep that in mind.

Gender-Affirming Hormone Therapy (12:33)

Anyway, moving on to gender-affirming hormone therapy.

This is defined by Johns Hopkins Medicine as treatment in which people take hormones such as estrogen or testosterone or hormone blockers that help achieve physical characteristics that are more masculine or feminine.

Now, don't confuse puberty blockers with hormone blockers.

They're different things. Instead, gender-affirming hormone therapy uses medicine to replace or suppress the hormones your body makes, typically estrogen and testosterone, that influence your outward appearance after puberty.

And this is used for people have already gone through puberty but haven't had genital surgery.

It's prescribed by a primary care provider or endocrinologist and can be part of a pre-surgical plan or a standalone service for adult patients.

And the three hormones used during this are estrogen-based therapy, which is typically taken via skin patch, pill, gel, or injection.

And this medicine blocks testosterone production and adds estrogen for breast growth and fat redistribution.

Next is testosterone therapy, which is typically administered via injection in the stomach or in the muscles of the glutes or thigh, and adds testosterone.

And lastly, there's hormone blockers, which blocks the body's own testosterone production. Now, for gender-affirming hormone therapy, there are some changes from the hormones that are permanent.

Things like breast development for people who take estrogen and voice deepening and facial and body hair growth for people who take testosterone will not go away if they stop taking the hormones.

But again, this type of therapy is for adults who are making their own medical decisions.

Also, from an emotional standpoint, during gender-affirming hormone therapy, people will go through what is called a second puberty.

Similar to puberty, they may experience mood swings, anxiety, and depression.

The Cost of Gender-Affirming Care (14:05)

And shifting from what it is, a lot of people who are against gender-affirming care point to insurance costs and how taxpayer dollars are going to transgender for everyone.

So, I wanted to see what I could find regarding that. Unfortunately, there isn't a ton of data out there, and what is available is dated.

Now, I did find a study published in the Journal of Law, Medicine & Ethics in fall 2022, which cites data from 2019 that found that the annual cost of providing gender-affirming care for transgender people with health insurance was $1,776 per person, or six cents per member per month.

And to put that in perspective, a 2025 Williams Institute report estimates that 2.8 million people age 13 and older in the United States identify as transgender, which equals approximately 1% of the US population.

But that figure doesn't reflect the number of transgender people actually receiving gender-affirming care, since not all transgender individuals seek or have access to these services.

In fact, they cite the 2022 US Transgender Survey, which found that only about 60% of adult respondents received gender-affirming care.

Now, in a December 2025 Proposed Rule, the Centers for Medicare and Medicaid Services reported that approximately $31 million of Medicaid and CHIP spending in 2023 was used for gender dysphoria treatment for youth, ages 6 to 18.

Of that, $28.2 million was used for prescription drug hormone therapy and professional services associated with it, like lab work and office visits.

And nearly $2.2 million was used for surgery in an outpatient hospital setting. And $180,553 were used for surgery in an inpatient hospital setting.

And across all those categories, the majority of the spending was in the 15-to-18-year age bracket, with $17.8 million going to prescription drug hormone therapy and professional services associated with it, approximately $2,145,000 going to surgery in an outpatient hospital setting, and approximately $180,553 going to surgery in an inpatient hospital setting.

And again, that's the total dollars this report found that went to surgery in an inpatient hospital setting within that $31 million.

So, according to this, in 2023, there were no Medicaid or CHIP spending on surgeries in an inpatient hospital setting for youth under the age of 15.

And if you add that all up, the total spend for youths aged 15 to 18 is nearly $20.2 million, or approximately 65% of that $31 million.

Now I don't have any numbers that dive deeper into that 15-to-18-year age bracket, but most states recognize the age of 18 as being a legal adult who can make their own medical decisions.

So, I would assume that's why you see the greatest amount of spending in that age bracket.

And while $31 million total may seem like a lot, keep in mind that the total Medicaid and CHIP spending in 2023 was approximately $924 billion with a B.

So that means that 2023 spending on gender-affirming care, on youth ages 6 to 18, accounted for less than 0.004% of Medicaid and CHIP spending that fiscal year.

And while these figures reflect spending rather than the exact number of individuals receiving care, I think the fact that gender-affirming care represents such a small fraction of total Medicaid and CHIP spending suggests that the population seeking this care through these programs is also comparatively small.

Again, I know that population only looked at youth ages 6 to 18 who have received gender-affirming care, but let's try to factor in all the numbers we just talked about.

So quick refresher, 2.1 million adults and 724,000 youth identified as being transgender in 2025. About 60% of adult respondents received gender-affirming care in 2022.

And the 2019 annual cost of providing gender-affirming care for insured individuals was estimated to be $1,776 per person, or about six cents per member per month.

That means 60% of adults receiving gender-affirming care could be around 1.6 million adults per year.

Then, if we multiply 1.6 million adults per year by the estimated annual cost per person, which was $1,776, that could mean about $2.2 billion per year for adult gender-affirming care.

And if we combine that with the $31 million spent on youth who receive gender-affirming care in 2023, we get $2.231 billion, but to simplify it, let's just round it up to $2.3 billion.

So, if we compare that number to the total Medicaid and CHIP spending in 2023, which again, was $924 billion, that equals 0.25% of the total Medicaid and CHIP spending.

So still, that's less than 1% of spending. Again, that is not a proven fact, since there is limited data out there. That's just my hypothesis, given the numbers that are available.

But just to put that in perspective, in 2024, GLP-1s like Ozempic accounted for over 8% of all Medicaid prescription drug spending before rebates.

So, for those who argue against gender-affirming care because of its cost, in my opinion, you don't really have much of an argument.

The Politics of Gender-Affirming Care (18:39)

Anyway, moving on from numbers to politics. I'm sure you've seen or heard headlines over the past few years regarding legislation around gender-affirming care.

So, looking at the current landscape, according to KFF, a leading nonpartisan nonprofit health policy organization, 27 states have enacted laws and policies limiting youth access to gender-affirming care.

24 states impose professional or legal penalties on health care practitioners providing minors with gender-affirming care.

And 50% of trans youth ages 13 to 17 live in a state that has enacted a law or policy limiting access to gender-affirming care.

And these are all relatively new laws, with the first being passed by Arkansas, shocker, in 2021. And by January 2024, that number increased more than fivefold.

And while these specifically target gender-affirming care for trans youth, there are laws affecting the adult population as well.

In May 2023, Florida, because it's Florida, passed SB 254, which requires specific provider consent and reporting requirements before adults can receive hormones and related care.

In June 2023, a federal judge blocked the part of the law targeting trans youth, saying it was likely unconstitutional, but left the adult restrictions in place.

In September 2023, the court refused to block the adult portion, meaning those restrictions continued to apply.

And in June 2024, that same judge permanently blocked the entire law, including the parts affecting adults, ruling that SB 254 couldn't be enforced at all.

Florida immediately appealed, and in August 2024, the appeals court paused that block, meaning the law can be temporarily enforced again while the appeal is ongoing.

On January 20, 2025, Trump issued Executive Order 14168, titled Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government, which ordered the withdrawal of federal recognition for transgender people and mandated that federal departments cease all funding for gender-affirming care and gender ideology programs.

Additionally, the administration has proposed rule changes that would stop the federal government from paying for gender-affirming care through programs like Medicaid and Medicare.

On February 27, 2025, Iowa Senate File 418 was enacted, which took effect on July 1, and it removed gender identity as a protected class from the Iowa Civil Rights Act, which has broad implications for adults in employment, housing, public accommodations, health care, discrimination, and more. It also enabled the state to ban Medicaid coverage for hormone therapy and gender-affirming surgery, which then formally occurred as part of the state budget implementation on July 1.

On March 28, 2025, Kentucky's legislature overrode Governor Beshear's veto of HB 495, which bans the use of Medicaid funds for gender-affirming care for transgender adults as part of its provision.

This law also relegalized conversion therapy and bans publicly funded gender-affirming care for certain populations, like incarcerated people.

And as of recording this, the following 11 states ban gender-affirming care coverage via Medicaid funding: Arizona, Florida, Idaho, Iowa, Kentucky, Missouri, Nebraska, Ohio, South Carolina, Tennessee, and Texas.

The Gender-Affirming Care Double Standard (21:34)

And to round out this episode, I just wanted to highlight some MAGA fanatics who have appeared to receive gender-affirming care themselves.

Now, just as a disclaimer, these examples come from an article in Pride and are all alleged, since none of these individuals have publicly confirmed this as fact.

But kicking it off, we have Matt Gaetz, who's rumored to use Botox and other injectables. Lara Trump may have had Botox fillers, a nose job, and a facelift.

Kimberly Guilfoyle is said to have lip and cheek fillers, along with other enhancements. Elon Musk is speculated to have had a hair transplant, neck lift, fillers, and Botox.

Laura Loomer's look has been described as heavily altered, particularly with cheek enhancements.

George Santos' facial features suggests he may have used fillers or Botox to plump his cheeks and lips. And Ron DeSantis is often questioned about wearing lifts in his shoes or boots.

Episode Closing (22:18)

So, there you have it, an overview of the spectrum of gender-affirming care. And again, not telling you what your opinion should be on the matter.

But I think it's important we educate ourselves on what it is, since it's clearly being generalized as transgender for everyone, which isn't the case.

And connecting it back to the tarot, the Four of Cups in reverse. Again, this card is telling us that we're in a period of introspection and withdrawal.

And while being withdrawn sometimes carries a negative connotation, it doesn't have to be.

This card is full of reflective and meditative energy, so withdrawing can allow us to better connect to ourselves, to achieve stability.

It's inviting us to step back from the noise, question what we've passively accepted, and consciously decide how we want to re-engage.

And as it relates to gender-affirming care, politically speaking, things are very tumultuous. There are a lot of opinions and a lot of incorrect statements being made and accepted as fact.

And it's very easy to feel uninspired, disillusioned, and disappointed with the world around us. God knows I am.

But while it may be easy to hide from those things, it won't help fix the situation, because we can't avoid things forever.

Instead, we need to check in with our inner selves to understand what we need to confront the situation we're withdrawing from.

And in the case of this episode, maybe it's taking the time to understand what gender-affirming care is and isn't, so we can better educate ourselves and develop a more informed opinion.

Again, not telling you what to believe or support, but let's confront any bias we may have and understand the facts so we're not just making noise.

And that extends beyond today's conversation to just life in general.

Regardless of our identity, in the face of these politically divisive times, I think it's important that we confront things by living authentically and saying, yes, I am.

Remember, change comes from within, so we can be the change we so desperately need to see in the world right now.

Connect with A Jaded Gay (23:52)

Anyway, thank you all for listening. I hope you found this informative. You know the drill. If you have any questions or feedback, you can reach out to me rob@ajadedgay.com.

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For more information on this topic, episode resources, blog posts, links to merchandise, socials, all that fun stuff, you can visit the website ajadedgay.com.

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And remember: every day is all we have, so you gotta make your own happiness.

Mmm-bye.

Outtake (25:21)

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Are gonadotropin. Are gonadotropin releasing hormone agonists.