Since President Donald Trump returned to office in January 2025, a significant portion of the conservative policy blueprint known as Project 2025 has moved from theory into federal action, particularly in areas affecting transgender health care.
Project 2025, developed by the Heritage Foundation and allied groups, is a sweeping roadmap outlining how a second Trump administration could rapidly restructure federal agencies, civil rights enforcement, and health policy. While Trump distanced himself from the plan during the campaign, policy trackers and civil rights groups say many of its recommendations are now reflected in executive orders and administrative directives issued during his second term.
Executive Orders Target Gender-Affirming Care
One of the most consequential moves came in January, when Trump signed an executive order directing federal agencies to end support for gender-affirming medical care for minors. The order instructs agencies to restrict the use of federal funds for puberty blockers, hormone therapy, and related care for individuals under 19, framing such treatment as harmful despite objections from major medical associations.
The directive closely mirrors Project 2025 language calling for the federal government to classify gender-affirming care as unsafe and to sever public funding streams connected to it. While the order does not directly ban care nationwide, it places pressure on hospitals, insurers, and state Medicaid programs that rely on federal funding.
Several health systems have since paused or reevaluated services for transgender youth, citing regulatory uncertainty and fear of losing federal reimbursement.
Redefining Sex in Federal Policy
In a separate order issued early in the administration, Trump directed federal agencies to define sex strictly as male or female based on sex assigned at birth. The change removed gender identity from federal definitions used in health care programs, civil rights enforcement, and benefits administration.
Advocates warn the shift has broad implications for transgender patients, including how insurance claims are processed, how discrimination complaints are handled, and how federal data on health outcomes is collected.
Project 2025 explicitly calls for eliminating gender identity from federal law and policy, arguing that prior administrations improperly expanded civil rights protections without congressional approval.
HHS Report Fuels Policy Shift
Midway through 2025, the Department of Health and Human Services released a report asserting that gender-affirming care for minors lacks sufficient evidence of safety and effectiveness. The report has been widely criticized by medical professionals, who say it selectively cites data and ignores decades of clinical practice.
The findings have been used by the administration to justify further restrictions on coverage and to defend ongoing rule changes affecting Medicaid and other federally supported programs.
Democratic-led states and advocacy organizations have filed multiple lawsuits challenging the report’s use in policymaking, arguing that it contradicts established medical consensus and violates federal nondiscrimination laws.
Legal Challenges Mount
More than a dozen states, along with civil rights groups, are now engaged in litigation seeking to block or limit the administration’s actions on transgender care. Courts have issued temporary injunctions in some cases, but many policies remain in effect while lawsuits proceed.
Legal experts say the administration’s approach relies heavily on executive authority and agency rulemaking, allowing it to advance Project 2025 goals without congressional approval. That strategy, they note, makes the policies harder to overturn quickly, even when challenged.
How Much of Project 2025 Has Been Implemented
Policy trackers say a substantial share of Project 2025’s recommendations are already reflected in federal actions taken during Trump’s first year back in office.
Multiple reviews have found that a large portion of the plan’s policy objectives have been implemented or are actively underway through executive orders, agency guidance, and proposed regulations. These include restrictions on gender-affirming care, the removal of gender identity from federal policy, limits on transgender military service, and the rollback of diversity and inclusion initiatives.
Because most of these changes rely on administrative authority rather than legislation, they have moved quickly and remain in place unless blocked by courts.
What to Expect in 2026
Advocacy groups and policy experts say several issues are likely to remain central in 2026.
Federal agencies are expected to finalize proposed rules that would further restrict Medicaid and other public insurance coverage for gender-affirming care for minors. Additional efforts may extend coverage limits affecting adult transgender patients enrolled in federal health plans.
The administration is also expected to continue enforcing binary sex definitions across federal programs, affecting civil rights enforcement, data collection, and access to federally regulated spaces and services.
Legal battles over the scope of federal authority and the legality of these policies are expected to intensify, with several cases likely to reach higher federal courts in 2026.
The Bottom Line
For transgender individuals and families, the cumulative effect has been uncertainty, disruption of care, and increased fear about the future of medical access. Advocates report growing confusion among providers and patients about what services remain legal or reimbursable, particularly for youth and low-income individuals who rely on public insurance.
While court challenges continue, the direction of federal policy under Trump’s second term is clear. Measures outlined in Project 2025 are no longer hypothetical. They are shaping how the federal government approaches transgender health care, with immediate consequences for access, coverage, and civil rights protections.
As legal battles unfold, the outcome may determine whether these changes become a lasting framework for federal health policy or are rolled back through the courts or future administrations.
