Over the past five years, 27 states have enacted laws restricting puberty blockers, cross-sex hormones, and surgeries for the purpose of gender transition in minors. In response, a nationwide network has emerged to help families continue medically transitioning their children in defiance of the law.
Transgender activists and their allies fiercely oppose these laws, arguing that they deny children access to “lifesaving healthcare.” Across the country, LGBT advocacy nonprofits have partnered with medical providers and other organizations to offer financial assistance, arrange flights, and refer families to providers willing to treat children from states where these interventions are restricted.
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The most prominent organization in this network is the Campaign for Southern Equality (CSE), a North Carolina-based LGBT advocacy nonprofit. In 2023, CSE launched the Trans Youth Emergency Project (TYEP), which has since expanded operations to all 27 states with restrictions on medical gender transition for minors, working with more than 130 local and regional partners nationwide. The project connects families with cooperating medical providers, helps pay for appointments at some of those clinics, and has distributed more than $1 million in travel grants to over 1,200 families.
But the effort is not limited to helping families travel to states where these interventions remain legal. An undercover City Journal investigation found that many of CSE’s recommended medical providers—with the organization’s knowledge—described ways to circumvent state restrictions and allow minors to continue receiving medical interventions in their home states. Some providers and their staff discussed using diagnoses other than gender dysphoria to make it easier for families to obtain prescriptions or insurance coverage—a practice that has attracted fraud investigations in the past. Others described sending prescriptions to pharmacies in states with bans or mailing medications directly to patients’ homes, even though some state laws also prohibit supplying these drugs to minors for gender transition. Some providers discussed conducting virtual appointments with patients in states where gender-transition medications are restricted for minors, while others required patients to connect from states where the interventions remain legal but did not appear to have reliable procedures for verifying their physical location.
My investigation began by filling out an application on CSE’s website, posing as the mother of a child seeking gender-transition treatments in Nashville, Tennessee, where they have been prohibited since 2023. After receiving an email response, I was connected with Amanda, one of the organization’s “care navigators,” who arranged to speak with me on the phone.
During our first phone conversation, I explained that my 11-year-old daughter had recently begun identifying as nonbinary and used both they/them and she/her pronouns. I deliberately described a fictional child with no longstanding history of cross-sex identification who had never been evaluated by a health-care professional for gender-related concerns. I brought up the topic of using puberty blockers as a way to give my fictional daughter “more time to decide” and asked Amanda whether it was accurate to characterize them as a “pause button on puberty.”
“That is exactly correct,” Amanda replied enthusiastically, praising me for doing my research and educating myself. Eleven, she assured me, was a good age to begin considering the treatment.
When I asked whether my daughter’s nonbinary identification might prevent her from receiving puberty blockers, Amanda answered, “Absolutely not.” She explained that nonbinary children fall under the transgender umbrella and that doctors should not deny them treatment because they lack the language to describe their feelings. Instead, they should defer to a child’s understanding of their own body and what they want for themselves.
Amanda said that CSE maintains a “substantial list” of physicians and clinics and bases referrals on a child’s age, location, and the family’s preference. She provided three options, including clinics in Illinois and Michigan and a Georgia-based telehealth provider, and said she could offer more if needed. When I asked how CSE selects its recommended providers, Amanda said, “we reach out, we do a full screening, we chat with them, we make sure that they are okay being added to our list. So, we have an entire process.” When I asked whether both parents needed to consent to treatment, Amanda said that even when parents disagree about medical interventions for their child, providers typically require approval from only one parent or guardian.
Amanda also emphasized that CSE monitors changing state laws daily. She said that while many states prohibit prescribing gender-transition medications to minors for gender dysphoria, the medications themselves remain legal because they are also prescribed for other medical conditions. “The thing is that the prescribing of that medication is not illegal,” Amanda told me. “It is the prescribing for gender dysphoria from a local doctor that would not be okay.” She said that “a lot of folks are able to get the meds locally,” either through pharmacies in their home states, including Tennessee, or through mail-order services that deliver medications directly to their homes. “There are all sorts of ways to access,” she added.
Amanda explained that once I had scheduled an appointment, I could contact CSE again to request a $500 travel grant to help cover transportation costs for the trip. The grant would be provided in advance and was available up to four times a year. “We’ve given out $1.2 million in the last year to families, and we plan to keep doing that,” she said.
A second conversation with CSE revealed a different approach to distributing travel grants. After submitting another application, a collaborator of mine posing as the Idaho parent of a 16-year-old who had recently begun identifying as transgender and wanted testosterone and “top surgery,” a euphemism for double mastectomy, spoke with another care navigator, Gracey. She provided referrals to five clinics in Oregon and California and said CSE had provider options across 15 states.
Gracey also described CSE’s partnership with Elevated Access, a nonprofit founded in 2022 that arranges free flights for people seeking abortions or gender-transition procedures. Its network includes volunteer pilots who transport passengers in private aircraft. The organization also helps arrange commercial flights for longer trips.
During the call, Gracey asked for the caller’s Venmo or PayPal information to send a $500 travel grant. “We ask that it’s used for travel, but we do not require any receipts,” she explained. When asked whether a medical appointment needed to be scheduled first, Gracey replied, “Oh no, you guys are already eligible, and I’ll send that payment today.” (City Journal did not accept or receive any funding.)
CSE has received substantial financial backing to support its operations, including donations from some of the country’s wealthiest philanthropists and progressive funding networks. Its 2024 federal tax filing reported nearly $3 million in annual revenue and $3.6 million in net assets. Contributions of at least $1 million each have come from MacKenzie Scott (ex-wife of Amazon’s Jeff Bezos), the Arcus Foundation, and the Chicago Community Trust. Other funders include the Ford Foundation, Oak Foundation, Tides Foundation, and Proteus Fund.
Aside from travel grants, CSE also helps finance medical services at clinics within its referral network. By July 2024, the organization said it had provided patient-care funding to eight clinics across the South. In a fundraising email this year, CSE director and transgender activist Allison Scott announced that the Trans Youth Emergency Project had distributed $2 million, with approximately $1 million going directly to families through travel grants and more than $1 million to its “frontline partners working directly with trans youth.”
Federal tax filings show that CSE awarded a combined $15,000 in health-care and patient-care funding to QueerMed, a telehealth practice providing puberty blockers and cross-sex hormones to minors, and $45,000 to CHOICES Medical Services, which prescribes cross-sex hormones to patients 16 and older at its Illinois clinic. CHOICES lists CSE among its funding partners. In an undercover call, a CHOICES representative said its Southern Youth Equality Fund covers appointments for eligible patients aged 16 to 18, including Tennessee residents. Other recipients of health-care grants included Mountain Area Health Education Center, Western North Carolina Community Health Services, Planned Parenthood South Atlantic, and Trust Women Foundation.
At another clinic in its referral network, CSE also helps cover the cost of appointments at Outpatient Family Medicine Transformed, a private practice in Bloomingdale, Illinois. One of Amanda’s most enthusiastic recommendations was this clinic’s physician, Dr. Jessica Lapinski.
“Dr. Lapinski is absolutely incredible,” Amanda said, explaining that she had helped many families with younger children.
Lapinski charges a $170 monthly membership fee for minors seeking gender-transition medical interventions, with medications and laboratory services billed separately. Her practice does not accept government-funded insurance. When I contacted the clinic, an employee named Jaye told me that CSE could cover the full year of membership fees, totaling $2,040.
During our conversation, I explained that I lived in Tennessee, where “gender-affirming care” is prohibited for minors. Jaye told me the clinic had an in-house pharmacy that stocked puberty blockers and worked with specialty pharmacies that could mail estradiol and testosterone vials directly to my home or send prescriptions to my local pharmacy.
When I asked whether pharmacies would know why the medications were being prescribed, Jaye said they would not, because the clinic used a general “endocrine disorder” diagnosis code for labs and medications. He said the gender dysphoria code was only used when seeking approval for puberty blockers.
Endocrine disorder refers to conditions that affect the body’s hormone-producing glands. Using a false diagnosis code for patients who do not have a disorder to obtain insurance coverage has come under federal investigation as a potential form of fraud.
Jaye also confirmed that the clinic offered virtual follow-up appointments for out-of-state patients, where my family could participate from our home in Tennessee. Families typically traveled to Illinois twice a year, with virtual appointments between visits.
Lapinski has publicly advocated continued access to pediatric gender-transition medical interventions. According to reporting on her practice, demand has surged as Chicago-area hospitals have ended their pediatric gender programs under federal pressure. Jaye said the clinic has had an influx of patients from both inside and outside Illinois, and that there were approximately 70 children and families on its waiting list.
When I contacted Amanda at CSE again, I explained that Lapinski’s clinic had a long waiting list but that I liked how accommodating it was for out-of-state families, specifically mentioning the use of an endocrine disorder diagnosis to make obtaining medication easier. Amanda expressed no concern about the coding practice and instead offered referrals to three additional clinics. Her next set of recommendations included Main Line Health in Pennsylvania, where Dane Menkin serves as director of LGBTQ services. Menkin is a nurse practitioner and transgender activist who is a member of the World Professional Association for Transgender Health (WPATH).
When I contacted Main Line Health, Mary, a nurse working with Menkin, returned my call. She explained that my fictional child might need only one in-person appointment annually, with virtual follow-ups from my home state between visits. She added that prescriptions for gender-transition medications could be sent to Tennessee pharmacies or filled through mail-order services and delivered directly to my home.
When I mentioned another clinic’s use of alternative diagnoses, Mary confirmed that Dane knew “all the different tricks,” including using diagnostic codes that “don’t specifically say anything about gender.” When I brought up the use of an endocrine disorder diagnosis code as an example, she agreed.
At the WMed Health Family Medicine–Crosstown Clinic in Kalamazoo, Michigan, a representative discussing Dr. Kristi van der Kolk’s practice likewise described how prescriptions could be worded to accommodate restrictions in other states and indicated that this might involve alternative diagnosis codes, such as endocrine disorder. She also said that patients could attend virtual follow-up appointments while physically located in Tennessee. (Reached for comment, the clinic’s communications director said that it “follows applicable Michigan laws and regulations governing patient care and prescribing practices. Patients affirm during every telehealth visit that they are located within the state of Michigan for the appointment. We do not alter prescription wording or diagnosis coding to circumvent applicable legal restrictions.”)
The use of alternative diagnostic codes was not limited to small private practices. At Oregon Health & Science University’s Doernbecher Children’s Hospital, I asked Will, a representative of its pediatric gender program, about using an endocrine disorder diagnosis instead of gender dysphoria to make filling prescriptions in Tennessee easier.
“That is one possible avenue,” he acknowledged. He said the approach depended on what insurance would accept and confirmed that the hospital used similar methods. “It might be a technique that the clinic you’ve spoken with has said that they use, as it is one for ours,” he explained. If an insurance plan permits the alternative diagnosis, “then we’ll absolutely do that.” Will also said that prescriptions could be filled at pharmacies in patients’ home states or medications shipped directly to patients’ homes, including Tennessee, depending on insurance coverage.
Other clinics I spoke with did not endorse or were less certain about the use of alternative diagnoses but did discuss other ways to provide gender-transition medications to minors in states where they are prohibited. At Olive Tree Health Direct in Wixom, Michigan, I spoke directly with Dr. Rachel Nixon. She said she worked with a mail-order pharmacy called Honeybee that could mail medications, including testosterone, to a Tennessee residence. Fitchburg Family Clinic in Wisconsin, Endocrine Kids in Michigan, and Harmony HRT and Elevated Community Health in Colorado also discussed the possibility of shipping medications directly to patients’ homes. At Family Tree Clinic in Minnesota, a representative confirmed that prescriptions could be sent directly to Tennessee pharmacies. A representative at the UCSF Child and Adolescent Gender Center said the same might be possible, depending on insurance arrangements.
Randall Children’s Hospital in Oregon strictly limits its patients to those living in the Pacific Northwest, which includes Idaho, where gender-transition treatments for minors are banned. Although families must travel to Portland for their appointments, the representative said that prescriptions could be filled at Idaho pharmacies or delivered to patients’ homes through Oregon pharmacies.
Another growing business model involves telehealth-based services that provide gender-transition medications to patients across the country. CSE lists several virtual hormone providers on its website, including Plume, FOLX, True U Clinic, and QueerMed, though their services and age requirements differ.
One of Amanda’s recommendations was QueerMed, whose office manager, Ashley, explained how the process worked. Families could drive into a state where the medications remained legal and the clinician was licensed, stop at a restaurant or rest area, and conduct a video appointment in their car before returning home. For puberty blockers, Ashley said the medications could be shipped through a specialty pharmacy directly to the family’s Tennessee address. One of QueerMed’s providers would instruct the family on how to administer the injections at home.
QueerMed uses Healow, an online patient platform whose privacy policy states that it may collect IP addresses and other data that can indicate a user’s location. When I asked Ashley how QueerMed verifies that patients had actually crossed state lines, she said staff could not view the location information collected by the online portal, and patients were not required to provide additional proof of their location. An email reprinted on a Reddit forum from QueerMed’s founder, Dr. Izzy Lowell, stated, “We rely on your report during the visit and have no way of tracking your location.”
Through a series of emails, Lowell first appeared to confirm that this account was correct, writing that “if you had reached out to me directly, I would have told you all of this.” She subsequently demanded that we not print her confirmation. Then, in another follow-up email, Lowell stated that QueerMed does not mail medications to anyone and claimed that QueerMed’s “providers verify every patient’s location for every visit, in compliance with applicable telemedicine laws.”
Other clinics in CSE’s referral network had stricter requirements. Cedars-Sinai’s Pediatric and Adolescent Gender Wellness Clinic in Los Angeles and UCSF Benioff Children’s Hospital Oakland, while willing to treat out-of-state patients, required them to attend appointments and pick up prescriptions in California. They each described using gender-dysphoria diagnoses rather than alternative diagnostic codes.
Even when treating children from hundreds or thousands of miles away occurs within legal boundaries, the practice still presents ethical problems and creates additional medical risks. Puberty blockers and cross-sex hormones require regular monitoring and can cause serious adverse effects. When parents obtain these medications for their children from out-of-state providers, they may be reluctant to disclose them to physicians in their area out of fear of scrutiny. If complications arise, they may delay seeking prompt in-person medical attention.
CSE describes the restrictions as “cruel laws” denying children access to “lifesaving healthcare.” But these laws were enacted amid serious concerns about exposing children to powerful medical interventions whose long-term safety and efficacy has not been established. Systematic reviews have found that the evidence supporting puberty blockers and cross-sex hormones for minors was of “low quality” and “very low certainty.” Research has found no evidence that these interventions prevent suicide, despite repeated claims that they are medically necessary and lifesaving.
My investigation primarily centered around a fictional 11-year-old who had only recently begun identifying as “nonbinary.” I wanted to show how far the gender-affirming care model has expanded and how eager some practitioners were to treat minors whose gender-related concerns might turn out to be temporary. The providers I shared this scenario with had no problem treating a nonbinary child. When I asked how soon she could obtain medication, many providers I questioned indicated that a prescription could generally be issued following an initial evaluation lasting one to several hours.
Sex nonconformity, including personality, preferences, and behaviors that do not align with stereotypes associated with one’s sex, is a natural part of human variation, not a health condition requiring medical intervention. However, it can sometimes cause distress. When children experience distress, they often look to their environment for explanations, where they may encounter the transgender ideological framework. Rates of transgender identification have soared in recent years, particularly among adolescent girls. The gender-affirming model encourages children to understand their sex nonconformity as evidence of an “innate gender identity” at odds with their sex, but this understanding relies on a false interpretation of scientific evidence.
State laws restricting medical gender transition for minors have likely prevented many children from receiving these interventions. But CSE and its network of medical providers have found ways around these restrictions. Some states have enacted shield laws that protect medical providers from legal action, which can complicate enforcement. However, it may still be possible to hold medical providers, pharmacies, and organizations that knowingly facilitate unlawful treatment accountable under existing laws. It is up to state and federal authorities to investigate these practices to determine whether existing laws have been violated and, if not, devise new necessary safeguards.