Response To Rep. Miller Final - Clean - Docx - Completed

THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON, D.C. 20201
March 15, 2023
The Honorable Mary E. Miller

U.S. House of Representatives
Washington, DC 20515
Dear Representative Miller:
Thank you for your letter regarding the proposed rule “Nondiscrimination in Health Programs
and Activities” and information on puberty blockers included in the “Gender-Affirming Care and
Young People” fact sheet. I appreciate your engagement on these important topics.
Non-discrimination in health care is critical to support positive outcomes for gender diverse
adolescents. Specifically, providing medically necessary, unbiased, gender-affirming care has
been proven to improve overall quality of life for transgender and gender diverse youth, build
self-esteem, and lower adverse mental health outcomes.1,2 In the proposed rule
“Nondiscrimination in Health Programs and Activities,” we stated that there is no requirement
for private insurance companies or other covered entities to cover any particular procedure or
treatment. Additionally, the proposed rule specifically clarifies that it does not require the
provision of any health service when the covered entity has a legitimate, nondiscriminatory
reason for denying or limiting that service, including when the covered entity reasonably
determines that such health service is not clinically appropriate for that particular individual.
Consistent with the Supreme Court’s decision in Bostock v. Clayton County, GA, 140 S. Ct. 1731
(2020), HHS interprets Section 1557 and Title IX’s prohibitions on discrimination based on sex
to include discrimination on the basis of sexual orientation and gender identity. Under Section
1557, federally funded covered entities are prohibited from restricting an individual’s ability to
receive medically necessary care, including gender-affirming care, on the basis of their sex
assigned at birth or gender identity. HHS also recently proposed codifying this in its Notice of
1
Wagner J, Sackett-Taylor AC, Hodax JK, Forcier M, Rafferty J. (2019). Psychosocial Overview of Gender-Affirmative Care.
Journal of pediatric and adolescent gynecology, (6):567-573. doi: 10.1016/j.jpag.2019.05.004. Epub 2019 May 17. PMID:
31103711.
2
Hughto JMW, Gunn HA, Rood BA, Pantalone DW. (2020). Social and Medical Gender Affirmation Experiences Are Inversely
Associated with Mental Health Problems in a U.S. Non-Probability Sample of Transgender Adults. Archives of sexual behavior,
49(7):2635-2647. doi: 10.1007/s10508-020- 01655-5. Epub 2020 Mar 25. PMID: 32215775; PMCID: PMC7494544.
Page 2
Proposed Rule Making (NPRM) on Section 1557.3 HHS remains committed to supporting the
rights of individuals to access medically necessary care without discrimination.
Further, the “Gender-Affirming Care and Young People” fact sheet provides research-based
information to explain the importance of gender-affirming care which includes the options of
puberty blockers and hormone therapy.4 Expert developed resources referenced within this fact
sheet, such as Transgender and Gender Diverse Children and Adolescents, provide details
regarding puberty blockers and questions to ask providers for safest options and considerations.
Major medical associations in the United States, including the American Medical Association
(AMA),5 the American Academy of Pediatrics,6 American Academy of Child and Adolescent
Psychiatry,7 the Pediatric Endocrine Society,8 and the Society for Adolescent Health and
Medicine,9 hold that gender-affirming care is medically necessary, safe, and effective care for
transgender and nonbinary children and adolescents. Additionally, puberty blockers and
hormone therapy have demonstrated positive impacts on youth mental health outcomes. Puberty
blockers have been safely prescribed to cisgender children for many decades. According to the
AMA, “[g]ender-affirming care is medically-necessary, evidence-based care that improves the
physical and mental health of transgender and gender-diverse people.”10
The NPRM published in the Federal Register on August 4, 2022, with a 60-day comment period,
and closed on October 3, 2022. HHS will carefully review and consider all comments received
during the rulemaking. Thank you for sharing your concerns with me. HHS remains committed
to fully enforcing all civil rights laws.
3
November 4, 2022. Nondiscrimination in Health Programs and Activities
https://www.federalregister.gov/documents/2022/08/04/2022-16217/nondiscrimination-in-health-programs-and-
activities; September 22, 2022. Section 1557 of the Patient Protection and Affordable Care Act.
https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html.
4
November 4, 2022. Fact Sheet: Gender-affirming Care and Young People.
https://opa.hhs.gov/sites/default/files/2022-03/gender-affirming-care-young-people-march-2022.pdf.
5
American Medical Association. (2021, June 15). AMA reinforces opposition to restrictions on transgender medical
care [Press release]. https://www.ama-assn.org/press-center/press-releases/ama-reinforces-opposition-restrictions-
transgender-medical-
care#:~:text=%E2%80%9CGender%2Daffirming%20care%20is%20medically,and%20gender%2Ddiverse%20peop
le.%E2%80%9D.
6
Rafferty, J., Yogman, M., Baum, R., et al. (2018). Ensuring comprehensive care and support for transgender and
gender-diverse children and adolescents. Pediatrics, 142(4).
7
AACAP Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse. (n.d.).
https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-
Based_Care_for_Transgender_and_Gender_Diverse.aspx.
8
Lopez, X., Marinkovic, M., Eimicke, T., Rosenthal, S. M., Olshan, J. S., & Pediatric Endocrine Society
Transgender Health Special Interest Group (2017). Statement on gender-affirmative approach to care from the
pediatric endocrine society special interest group on transgender health. Current opinion in pediatrics, 29(4), 475–
480. https://doi.org/10.1097/MOP.0000000000000516.
9
SAHM statement in opposition of state legislation barring evidence-based treatment (n.d.). Retrieved September
22, 2022, from https://www.adolescenthealth.org/Advocacy/Advocacy-Activities/2019-(1)/SAHM-Opposition.aspx
10
American Medical Association. (2021, June 15). AMA reinforces opposition to restrictions on transgender
medical care [Press release]. https://www.ama-assn.org/press-center/press-releases/ama-reinforces-opposition-
restrictions-transgender-medical-
care#:~:text=%E2%80%9CGender%2Daffirming%20care%20is%20medically,and%20gender%2Ddiverse%20peop
le.%E2%80%9D.
Page 3
If you have further thoughts or questions, please have your staff contact the Office of the
Assistant Secretary for Legislation at (202) 690-7627. Again, thank you for your letter and
perspective. Your co-signers will also receive a copy of this letter.
Sincerely,
Xavier Becerra
Cc:
Hon. Lauren Boebert

Hon. Debbie Lesko
Hon. Bob Good
Hon. Marjorie Taylor Greene

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THE SECRETARY OF HEALTH AND HUMAN SERVICES

WASHINGTON, D.C. 20201

March 15, 2023

The Honorable Mary E. Miller

Dear Representative Miller:

Hon. Lauren Boebert

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