In recent weeks, two parallel developments have reshaped the landscape of transgender health care in the United States. The Trump administration, through the Department of Health and Human Services and the Centers for Medicare and Medicaid Services, has moved to restrict or effectively eliminate federal support for gender-affirming care for minors. At the same time, the U.S. House of Representatives narrowly passed a bill introduced by Rep. Marjorie Taylor Greene that would criminalize doctors who provide such care to transgender youth.
While supporters of these actions frame them as protective or precautionary, history and public health research point to a different outcome. When medical care is restricted, stigmatized, or criminalized, it does not disappear. It moves underground.
For transgender youth, these policy shifts do not eliminate the need for care. They sever access to regulated, supervised, evidence-based medicine. The result is not safety. It is risk.
Demand Does Not Vanish When Care Is Banned
Transgender youth do not seek gender-affirming care because of political trends or cultural influence. They seek it because untreated gender dysphoria is associated with elevated rates of depression, anxiety, self-harm, and suicidality. Major medical associations have long recognized this reality, which is why gender-affirming care exists in the first place.
When federal agencies restrict funding and lawmakers threaten criminal penalties, the underlying need remains. What changes is the path available to meet that need.
History provides countless examples. Prohibition did not eliminate alcohol consumption. Abortion bans did not end abortions. Restrictions on HIV medication access did not stop people from seeking treatment. In every case, care shifted from regulated systems to informal, unregulated networks.
Gender-affirming care is no different.
How Policy Forces Care Underground
When legal pathways are cut off, transgender youth and their families face impossible choices. Do nothing and hope dysphoria resolves on its own. Or seek alternatives outside traditional medical systems.
For many, inaction is not survivable.
This is where gray and black market sources enter the picture. These include online hormone sellers, international pharmacies operating outside U.S. regulations, peer-to-peer hormone sharing, and underground guidance networks that exist specifically because formal systems have failed.
Some of these sources operate in legal gray zones. Others are explicitly illegal. None are subject to the safety standards, monitoring, or accountability required of licensed medical professionals.
Yet when doctors are legally barred from helping, these sources become the only option.
Why Youth Avoid Licensed Medical Providers
Criminalization does more than remove services. It destroys trust.
When laws threaten doctors with prison or loss of licensure, providers respond predictably. They stop offering care. They decline new patients. They avoid even discussing gender-related concerns for fear of liability.
From the perspective of transgender youth, this transforms clinics from places of support into potential sites of harm. Disclosure becomes risky. Asking questions becomes dangerous. Medical visits become surveillance rather than care.
This fear is not hypothetical. Youth in states with restrictive laws already report avoiding doctors entirely, even for unrelated health issues, out of concern that being transgender could trigger investigation or denial of care.
Once trust collapses, young people stop seeking help where it is safest.
The Internet Becomes the Doctor
In the absence of accessible medical care, the internet fills the gap.
Transgender youth increasingly turn to online forums, social media, encrypted messaging apps, and international suppliers to learn how to self-manage hormones. These spaces often provide detailed information, dosing guides, and peer support. They also lack safeguards.
Some information shared is accurate. Much of it is incomplete or context dependent. Without blood work, monitoring, or professional oversight, even well-intentioned self-treatment carries risks.
But from the perspective of a young person denied care, these risks may feel preferable to untreated dysphoria or despair.
Financial Barriers Compound the Problem
Federal moves to cut Medicaid and Medicare support further narrow access. Gender-affirming care is already expensive. Without insurance coverage, it becomes unattainable for most families.
When care is unaffordable through legal channels, underground sources appear financially attractive. Online sellers often market hormones at a fraction of the cost of clinic-based care. No appointments. No documentation. No waiting lists.
This economic pressure does not exist in a vacuum. Transgender youth are more likely to experience family rejection, housing instability, and poverty. Policies that remove coverage do not just limit access. They push vulnerable youth toward the cheapest option available, regardless of safety.
Criminalization Does Not Stop Care. It Stops Oversight.
One of the most dangerous myths underlying these legislative efforts is the idea that criminalization prevents harm. In reality, it removes the very structures that reduce harm.
Licensed providers are required to follow evidence-based guidelines, obtain informed consent, monitor patients, and adjust treatment as needed. They are accountable to medical boards, professional standards, and malpractice law.
Black market sources are accountable to no one.
When care moves underground, adverse effects go unnoticed. Complications go untreated. Youth are left to manage complex medical decisions alone or with peers who are doing their best but lack training.
This is not protection. It is abandonment.
Psychological Consequences of Forced Secrecy
Beyond physical risks, underground care carries profound psychological costs.
Seeking hormones in secret reinforces shame and isolation. It teaches young people that their needs are illegitimate and dangerous. It discourages them from seeking help when something goes wrong.
Forced secrecy also fractures family dynamics. Parents who want to support their children may feel compelled to look the other way or assist quietly, fearing legal consequences. This undermines open communication and trust.
In trying to control gender-affirming care, these policies instead cultivate fear-based decision-making that benefits no one.
A Pattern Seen Before
Public health experts recognize this pattern because it has played out repeatedly. When needle exchange programs are banned, HIV transmission increases. When abortion access is restricted, unsafe procedures rise. When pain management is overcriminalized, patients turn to illicit opioids.
Each time, policymakers claim concern for safety. Each time, the result is greater harm. Transgender health care is entering the same cycle.
Who Bears the Cost
The burden of these policies does not fall evenly. Youth with supportive families and financial resources may find ways to navigate around restrictions, including traveling out of state or accessing private care.
Those without means are left with fewer options. Rural youth. Youth of color. Disabled youth. Youth in foster care. Youth whose families are unsupportive or hostile.
These are the young people most likely to turn to unregulated sources because they have nowhere else to go.
The Inevitable Outcome
The convergence of federal funding restrictions and symbolic criminalization sends a clear message. Transgender youth are not welcome in the medical system.
When a population is told repeatedly that their care is dangerous, controversial, or criminal, they do not stop needing care. They stop asking permission.
Gray and black market access is not a fringe response. It is the predictable outcome of policy that prioritizes ideology over reality.
What This Means Going Forward
If the stated goal of these measures is to protect children, they are failing on their own terms.
Protecting youth means ensuring access to safe, supervised, evidence-based care. It means building trust between patients and providers. It means reducing harm, not pushing it into the shadows.
Every barrier added to legitimate care strengthens underground alternatives. Every threat aimed at doctors increases the likelihood that youth will self-manage without guidance.
This is not speculation. It is how human behavior responds to prohibition.
The Bottom Line
The central question remains unanswered by proponents of these policies. If not doctors, then who? If not regulated clinics, then where? If not evidence-based medicine, then what replaces it?
Until policymakers grapple honestly with these questions, transgender youth will continue to find answers on their own. Often at great personal risk.
