During my time as a physician advisor and clinical leader over the past decade – spanning four presidential administrations – I have never seen such clear ideological pretense presented by the Centers for Medicare & Medicaid Services (CMS) as a regulatory priority.
But let me set the scene: on the first full day of work for CMS under the new administration, as previously reported on Monitor Mondays, a memo came out from then-acting Secretary of Health & Human Services (HHS), Dr. Dorothy Fink, indicating that the agency would “refrain from publicly issuing any document (e.g. regulation, guidance, notice, grant announcement) or communication until it has been reviewed and approved by a Presidential appointee1.”
Since that communications “freeze,” CMS has issued 23 public notices to date. Most of these are the subject of other recent Monitor Mondays guests’ segments: Medicare Advantage and Part D payment updates, Innovation Center and model program adjustments, and addressing prescription drug prices. But one announcement seems like a bit out of character for CMS: in its focus, its content, and its rigor.
If you have CMS.gov saved in your favorites, go to the “Newsroom” homepage, and you will see the fourth notice from the new CMS, dated March 5, titled, “CMS Alerts Hospital Providers on Protecting Children from Chemical and Surgical Mutilation2.”
If this headline sounds a little jarring to you – especially appearing on an official webpage – you are not alone. The intentional framing of gender health, and specifically, gender-affirming care (GAC), as “mutilation” is supposed to raise your hackles.
Years before, U.S. Senator Rand Paul used the phrase “genital mutilation” during the 2021 confirmation hearing of Dr. Rachel Levine for Assistant Secretary of HHS3, and ideological opponents of gender identity have since framed the debate along the lines of alarming medical terms.
In this case, it resulted in a Jan. 28 Executive Order, which is linked on HHS homepage under “Protecting Children,” using the same ideological framing4.
To be clinically clear: applying the term “mutilation” in the Executive Order’s meaning as any medical, pharmacological, or surgical intervention4 – i.e., altering the body’s function – would encompass just about any therapeutic offering in medicine, writ large.
So, at the very least, it is disingenuous to selectively apply it to a certain sub-specialty without definitive differences in the intervention from others. At worst, it is an example of the integrity of CMS falling prey to ideological influences, rather than scientific ones.
But speculation aside, let us get genuinely curious about the “Newsroom” release in question, QSSAM-25-02-Hospitals, examining it the way we would any other official posting. As a “Quality & Safety Special Alert Memo” (QSSAM), it serves as a relatively unique posting from CMS, among only three such publicly available alerts – and the only one under the new administration2.
Its point of origin is the CMS Center for Clinical Standards and Quality (CCSQ), whose functional statement indicates that it “serves as the focal point for all quality, clinical, medical science issues, survey and certification, and policies for CMS’s programs,” being led by career public health physicians5. The memos this agency posts are geared toward specific provider types, and are often reminders of existing obligations or requirements.
However, other than the formatting and the letterhead, the similarities between QSSAM-25-02-Hopsitals2 and other CMS memos6 (and, frankly, most other CMS notices, prior to Jan. 20) end there. Begin by identifying authorship. On the previous CCSQ memos, it is clearly noted from whence the notices came, namely the Directors of the “Quality, Safety & Oversight Group,” as well as the “Survey & Operations Group,” with the two groups’ Directors as the signatories6.
The new memo just indicates that it comes from CMS, without any identified individuals or signatory parties2.
From there, the focus and content of QSSAM-25-02-Hospitals strays from the neutral tone typical of other regulatory notices and the two prior CCSQ memos. Using a lexicon of terms and phrases evocative of negative emotions, the memo paints a dark caricature of gender health as an “under-developed body of evidence” causing “irreparable harm to some children” who “suffer” through exploration of their gender identity2. It confuses raw statistics7 obtained from reliable, peer-reviewed sources8-10 – amounting to only 4 of its 14 citations – with advocacy group position pieces11 from self-described “think-tanks” “promoting free-market solutions to social and economic problems,”12 frequently quoting religious leaders, not qualified medical professionals13.
One such source, accessed one day prior to the posting date of the QSSAM (March 5), disparagingly describes accredited and nationally renowned hospitals across this country as the “Dirty Dozen”14 that provide gender health services to some of the estimated 1.6 million Americans who identify as transgender7. The memo2 then further conflates guidelines developed by countries constrained by budgets for socialized healthcare systems15,16 with global standards of care, selectively omitting the most internationally authoritative publication on gender health, by the World Professional Association for Gender Health (WPATH)17.
In contrast to what seems like possibly a rushed, partisan posting containing opinions accessed within one day of becoming official, WPATH published its “Standards of Care, 8th Version” after five rigorous years of cross-disciplinary collaboration and research17.
Although the originally referenced Executive Order of Jan. 28 described WPATH by noting it “lacks [sic] scientific integrity”4, its publication includes a full description of its methods, entailing a Delphi process used to reach formal consensus statements, an assessment of bias risk using the Cochrane Risk of Bias Tool and ROBINS-I tool, external validation of references, conflict-of-interest disclosures by all members of the Evidence Review Team, six weeks of public comment including 2,688 comments, plus 68 pages of single-spaced references, and a description of the selection criteria used by the Johns Hopkins University Evidence Review team17. Yet, despite being cited in 1,299 other peer-reviewed articles18, the WPATH evidence appears nowhere in the March 5 QSSAM, which quizzically states there is a “lack of medical evidence” on the subject of gender-affirming care2.
This oversight by the unidentified author(s) of this CMS QSSAM is either neglectful or intentional. The differences between what we expect from CMS and what we see in this memorandum cannot be ignored.
If neglectful, then perhaps the newest members of CMS can learn from the experienced, career policymakers of CMS. If intentional, then the lack of concrete, policy-producing substance in this memo should give some hope that this is simply saber-rattling, and accept it for how it reads: a middle-school-level book report intended to provide the “review of existing literature on best practices” [Sec. 3(a)ii] within the 90-day time-frame requested by the Jan. 28 Executive Order4.
But if there is more to come – and a follow-up notification from the Health Resources and Services Administration (HRSA) that went out to fifty-nine children’s hospitals on March 6 seemed to suggest that there would be, to the tune of $367 million in at-risk awarded payments19 – then the onus is on those of us who are reading these notices and notice irregularities to say something.
1. Fink, D. “Immediate Pause on Issuing Documents and Public Communications – ACTION”. Department of Health and Human Services, Jan 21, 2025. https://www.documentcloud.org/documents/25502931-acting-hhs-secretarycommunications-memo-1-21-25/.
2. Centers for Medicare & Medicaid Services. “Protecting Children from Chemical and Surgical Mutilation”. Center for Clinical Standards and Quality, Mar 5, 2025. https://www.cms.gov/files/document/QSSAM-25-02-Hospitals.pdf.
3. NBC News. “Rand Paul criticized for trans ‘gender mutilation’ remarks in Rachel Levine hearing”. NBCUniversal Media, LLC, Feb 26, 2021. https://www.nbcnews.com/feature/nbc-out/rand-paul-criticized-trans-gender-mutilationremarks-rachel-levine-hearing-n1259004.
4. Trump, D. “Protecting Children from Chemical and Surgical Mutilation”. The White House, Jan 28, 2025.https://www.whitehouse.gov/presidentialactions/2025/01/protecting-children-from-chemical-and-surgical-mutilation/.
5. Center for Clinical Standards & Quality. “Functional Statement”. Centers for Medicare & Medicaid Services, Jan 20, 2025. https://www.cms.gov/about-cms/who-weare/leadership/center-clinical-standards-quality#biography-4.
6. Tritz K and Wright D. “Clarification of CMS’ Provider Enrollment Visits (all providers and suppliers) and Specific Disclosure Requirements for SNFs and NFs”. Center for Clinical Standards and Quality, Nov 4, 2024. https://www.cms.gov/files/document/qssam-25-1-all.pdf.
7. Herman, J.L., Flores, A.R., O’Neill, K.K. “How Many Adults and Youth Identify As Transgender in the United States?” UCLA Law, June 2022. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/.
8. Steensma, T.D. et al. “Gender identity development in adolescence.” Hormones and Behavior, July 2013, 64(2) pp 288-297. https://www.sciencedirect.com/science/article/abs/pii/S0018506X13000676.
9. Wright, J.D., Chen, L., Suzuki, Y., et al. “National Estimates of Gender-Affirming Surgery in the US.” JAMA Network Open. Aug 23, 2023, 6(8). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808707.
10. Chen, D. et al. “Consensus Parameter: Research Methodologies to Evaluate Neurodevelopmental Effects of Pubertal Suppression in Transgender Youth.” Transgender Health, Dec 11, 2020, 5(4). https://www.liebertpub.com/doi/10.1089/trgh.2020.0006.
11. American College of Pediatricians, “Gender Dysphoria in Children”. November 2018. https://acpeds.org/positionstatements/gender-dysphoria-in-children.
12. The Heartland Institute. “About Us.” 2025. https://heartland.org/about-us/.
13. Christian Medical & Dental Associations. “CMDA Ethics Statement”. Biological Integrity, Oct 30, 2021. https://biologicalintegrity.org/wpcontent/uploads/2023/08/Resources-CMDA-PDF-Transgender Identification-2021-October-2.pdf.
14. Do No Harm. “Stop the Harm Database.” A Project of Do No Harm, 2025. https://stoptheharmdatabase.com/about/.
15. NHS England. “Children and young people’s gender services: implementing the Cass Review recommendations.” National Health Service, Aug 29, 2024. https://www.england.nhs.uk/long-read/children-and-young-peoples-gender-servicesimplementingthe-cass-review-recommendations/.
16. Socialstyrelsen. “Care of children and adolescents with gender dysphoria.” December 2022. https://www.socialstyrelsen.se/globalassets/sharepointdokument/artikelkatalog/kunskapsstod/2023-1-8330.pdf.
17. Coleman E et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” Int J Transgender Health, Sept 15, 2022. https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644.
18. Taylor & Francis Online. Informa UK Limited, 2025. https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644#d1e2811.
19. Engels, T. Health Resources and Services Administration, Mar 6, 2025. www.hrsa.gov.
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