Youth gender clinics disclose how they evade state bans, deceive insurance: undercover sting

With the Trump administration successfully shielding its predecessor's mail-order abortion pill regime from legal challenge before midterm elections, depriving Democrats of a potent campaign issue while its Food and Drug Administration decides whether to reinstate in-person prescribing rules, a more tempting target is growing in visibility.

An undercover investigation by a center-right think tank purports to expose a network of activists and medical providers using deception to help families obtain and pay for so-called gender-affirming care – puberty blockers, cross-sex hormones and surgical removal of healthy breasts and genitals – that is prohibited where they live or not covered by insurance.

The Manhattan Institute's City Journal report highlights the Campaign for Southern Equality, which lost its primary cause when the Supreme Court legalized same-sex marriage nationwide, as the key hub linking families of children who identify as the opposite sex or no sex to medical providers willing to circumvent GAC restrictions on the books in most states.

It said many of CSE's recommended providers, "with the organization’s knowledge," coached families on how to "circumvent state restrictions and allow minors to continue receiving medical interventions in their home states," using non-gender dysphoria diagnosis codes to fool insurance and pharmacies and mailing medications directly to patients' homes.

It's not the first time North Carolina-based CSE has shown up on a list of organizations that allegedly facilitate the circumvention of state Medicaid restrictions and promote insurance billing fraud by obscuring the intended purpose of treatment approved for precocious puberty, hormone deficiencies and unspecific endocrine disorders, among other conditions. 

Medical advocacy group Do No Harm flagged CSE's work in a broader report this spring on the ecosystem of alleged GAC billing fraud.

CSE Executive Director Jasmine Beach Ferrara and Communications Manager Emma Chinn did not answer queries about the report's portrayal of CSE's work and, if uncontested, how CSE defends the work in light of federal investigations of GAC billing fraud.

The organization's staff page, still linked from its "about" page, has redirected to its home page for more than a year and a half, but Just the News found an intact archive with staff contacts from a week before President Trump's second inauguration in January 2025.

'The evidence of misconduct is astonishing'

The new report complements the Trump administration's recent enthusiasm for threatening to cut off federal money and prosecute providers for GAC billing fraud, and for improving care for detransitions by issuing new diagnosis codes that make them visible in medicine and help them get restorative treatment and insurance coverage.

In contrast to the Justice Department's hostility toward GOP-led states seeking to stanch the flood of abortion pills from out of state that render their pro-life laws toothless, DOJ's case against Texas Children's Hospital for hidden GAC practices on minors prompted a settlement that created the nation's first detransition clinic, which opened at TCH last week.

TCH whistleblower Eithan Haim recently posted what he called the first in a series of comprehensive reviews of detransitioners' medical records, with their consent, showing their doctors "employing what appears to be proxy diagnosis codes" as a "false pretext to secure insurance payment for hormones and surgery." 

The first review concerns Fox Varian, the detransitioner whose $2 million jury award against her medical providers for malpractice sparked panic across the industry. They used "breast hypertrophy" as a proxy for gender dysphoria to secure her double mastectomy, the same trickery recommended by CSE, according to Haim.

Rhode Island Hospital has also turned over more than 112,000 pages of records on GAC for minors in response to a DOJ administrative subpoena pursued through federal court in Texas. Though a Rhode Island federal judge banned DOJ from reviewing the records, the Texas federal court has required their submission for in-chambers review.

"While DOJ attorneys are fighting tooth and nail to obtain these records, establishment forces are doing everything they can to prevent that from happening," Haim said. "There is no mystery behind the unprecedented resistance to this otherwise standard request [...] the evidence of misconduct is astonishing."

Clinics use 'tricks' such as codes that 'don’t specifically say anything about gender'

Masquerading as a Tennessee mother seeking GAC for an 11-year-old nonbinary daughter with no "longstanding" history of gender confusion or healthcare evaluation for such, City Journal investigative reporter Christina Buttons said she connected with a CSE "care navigator" after filling out a form on the organization's Trans Youth Emergency Project page.

The Volunteer State's ban on GAC for minors is responsible for the Supreme Court's blessing of such laws more than a year ago, finding they classify based on age and medical use and refusing to recognize transgender people as a class.

"The providers I shared this scenario with had no problem treating a nonbinary child," Buttons wrote. "When I asked how soon [the girl] could obtain medication, many providers I questioned indicated that a prescription could generally be issued following an initial evaluation lasting one to several hours."

Buttons wrote on X that her investigation "uncovered practices that may violate state and federal laws and pose medical risks to children living hundreds or thousands of miles from their treating physicians."

Walking Buttons through the process of securing puberty blockers for her daughter without raising suspicion, the CSE navigator allegedly said prescribing the treatment is "not illegal" – unless it's explicitly for "gender dysphoria from a local doctor" – and that "a lot of folks are able to get the meds locally" through pharmacies or mail-order home delivery.

An Illinois clinic in CSE's referral network told Buttons that it 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," Buttons paraphrased the conversation.

The clinic uses a general "endocrine disorder" code for labs and medications to keep pharmacies in the dark about the purpose of the treatment, and Buttons' family could make virtual follow-up appointments between two visits to Illinois a year, the clinic employee allegedly said.

A Pennsylvania clinic referral told Buttons "my fictional child might need only one in-person appointment annually, with virtual follow-ups" from Tennessee, Buttons paraphrased. The nurse allegedly said prescriptions could be mailed directly or fulfilled through Tennessee pharmacies using "tricks" such as codes that "don’t specifically say anything about gender."

Asked about using an endocrine disorder code instead of a gender dysphoria code, a taxpayer-funded Oregon clinic allegedly told Buttons "that is one possible avenue" and "it is one for ours," subject to an insurance plan permitting the endocrine disorder diagnosis. Prescriptions could be mailed directly to her or filled at Tennessee pharmacies, the rep allegedly said.

A telehealth hormone provider told Buttons families can drive to 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," with puberty blockers "shipped through a specialty pharmacy" to her home, Buttons paraphrased.

Asked how the provider actually verifies patients have crossed state lines into a GAC-allowed jurisdiction, the officer manager allegedly said its staff couldn't view location information and patients were operating on the honor system. An email from the provider posted on a Reddit forum allegedly said it has "no way of tracking your location."

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