This week, Do No Harm submitted a comment on two rules proposed by the Centers for Medicare & Medicaid Services (CMS) that seek to restrict taxpayer funding of sex-rejecting interventions for minors.
The first rule would prevent hospitals from performing these procedures on minors as a condition of participating in Medicare and Medicaid programs.
The second rule would require state Medicaid and Children’s Health Insurance Program (CHIP) plans to provide that they will not pay for sex-rejecting procedures for minors; this would effectively cut off Medicaid/CHIP funding for these interventions.
Do No Harm’s comment begins by laying out the need for these rules. It explores the lack of evidence supporting child sex change interventions as a means of treating gender-distressed children, citing the fact that every comprehensive review, including the review published by the Department of Health and Human Services in 2025, has found the evidence base for these procedures to be weak.
Our comment lists multiple European countries that have restricted access to sex-rejecting procedures due to such findings.
The comment also cites the recent position statement by the American Society of Plastic Surgeons in which the organization recommended against sex-denying surgeries for minors, citing the lack of evidence.
Do No Harm’s comment also proposes several revisions to the language of the proposed rules.
First, our comment proposes definitions for “female,” “male,” and “sex” borrowed from the Chloe Cole Act, legislation that seeks to prevent healthcare providers from performing sex-rejecting medical interventions on children.
Considering that the proposed rule is targeting procedures that modify a child’s body to appear different than that of the child’s natal sex, the definitions of these terms are critical for the functioning of the rule. Do No Harm’s revised definitions are intended to guard against ambiguity.
Female is a person who naturally has, had, will have, or would have but for a congenital anomaly or intentional or unintentional disruption, the reproductive system that produces, transports, and utilizes the large gamete (ova) for fertilization.
Male is a person who naturally has, had, will have, or would have but for a congenital anomaly or intentional or unintentional disruption, the reproductive system that produces, transports, and utilizes the small gamete (sperm) for fertilization.
Sex means a person’s immutable biological classification, determined at the moment of conception, as either male or female.
Next, our comment proposes altering the definition of “sex-rejecting procedure” to more clearly encompass a broader array of medical interventions. The proposed rule currently defines sex-rejecting procedures as procedures that attempt to “align a child’s physical appearance or body with an asserted identity that differs from the child’s sex” by:
“(1) Intentionally disrupting or suppressing the normal development of natural biological functions, including primary or secondary sex-based traits; or
(2) Intentionally altering a child’s physical appearance or body, including amputating, minimizing or destroying primary or secondary sex-based traits such as the sexual and reproductive organs.”
However, these descriptions of “sex-rejecting procedure[s]” may not cover a broader range of “gender-affirming care” procedures that do not “destroy” sex-based traits, such as body contouring (among others). For this reason, Do No Harm proposed revisions to make clear that these broader range of procedures are included in the definition of “sex-rejecting procedure.”
Our proposed language would expand this universe of prohibited procedures to those that alter a child’s physical appearance by “intentionally changing a child’s body, including the child’s external appearance or biological functions, when the change is purposed to align the child’s body with the opposite sex.” The comment also proposes alternative revisions to this definition.
And third, the comment proposes language to clarify that restrictions on Medicaid/CHIP coverage for sex-rejecting procedures should explicitly exclude treatments for precocious puberty, a well-recognized pediatric endocrine condition.
