'Wolves in white clothing' - US report on gender medicine.

[ArabellaScott]

https://www.hhs.gov/sites/default/files/hhs-wolves-in-white-coats.pdf

This looks significant.

Ach sorry, 'white coats'. Muddling my sheep's clothing and the title.

https://www.hhs.gov/press-room/hhs-report-insurance-coding-sex-rejecting-procedures-minors.html

Report includes allegations of insurance coding fraud.

'The U.S. Department of Health and Human Services (HHS) today released a report Wolves in White Coats: How Doctors and Hospitals Pushed and Profited from the Fraud of “Gender Medicine,” a commissioned report examining insurance coding practices, perverse financial incentives, and the provision of sex-rejecting procedures for minors. Drawing on Centers for Medicare & Medicaid Services (CMS) Guidance, Department of Justice (DOJ) investigations, peer-reviewed scientific literature, hospital records, whistleblower testimony, nationwide insurance claims analyses, and interviews with patients and parents, the report presents HHS’ findings and recommendations about the industry pushing and profiting off so-called “gender medicine.”'

https://www.reuters.com/legal/litigation/trump-administration-accuses-hospitals-improper-billing-over-gender-care-minors-2026-08-13/

'According to the report, more than 225 hospitals and health systems established pediatric gender programs nationwide. The report also analyzes nationwide claims data from 2015 through 2025 and identifies approximately $50 million in insurance claims for puberty blockers billed using endocrine disorder diagnostic code E34.9 (Endocrine Disorder, Unspecified). It further reports that nearly $11 million in claims for patients ages 13–17 were billed using a diagnosis code for precocious puberty E301 — findings the report says warrant additional review of insurance coding practices.'

The claim here is that rather than claim 'gender incongruence' or whatever the current terminology is, HCPs were using wrong codes to bypass scrutiny.

This looks to me like it is really going to get insurers and lawyers ears pricking up.

And the US healthcare system is all about the billing/insurance/cost.

From the summary report:

'...the medical establishment created what the report describes as ‘captive patients,’ placing vulnerable children on a path toward potentially lifelong medical interventions.'

'All‑payer claims and cost data indicate nearly $120 million in billed charges for sex‑rejecting procedures involving minors since 2019. These charges include more than 5,500 surgical procedures and 8,500 courses of hormones or puberty blockers. The analysis concludes that these continuing interventions have created financially valuable patient populations for hospitals and associated specialties.
Cross-sex hormone therapy entails average yearly payer costs per patient ranging between $545 (androgens), $735 (estrogens), and $16,385 (for the more costly puberty-blocker GnRH). Surgical interventions, such as mastectomies, mammoplasties, and phalloplasties, can range from $12,000 to over $130,000.'

'Potentially Fraudulent Medical Coding

An analysis of the data suggests that some providers may have used diagnosis codes that did not accurately reflect patients' underlying conditions in order to obtain insurance coverage for sexrejecting procedures, particularly with ICD-10 code E34.9 (“endocrine disorder, unspecified”) and the ICD-10 codes for central “precocious puberty.”
Between 2015 – 2025, public and private insurance was billed nearly $50 million for puberty blocking drugs in patients aged 9-17 with Endocrine Disorder diagnoses (excluding precocious puberty, the typical indication for puberty blockers).
During this same timeframe, nearly $11 million was billed for puberty blockers, including to Medicaid and Medicare, for hundreds of patients between the age of 13 and 17 with a diagnostic code for precious puberty. By definition, anyone 13 or older cannot have a diagnosis of precocious puberty and should not be given puberty blockers at that age for this indication'

Thanks for the link, it's good that attention is being paid to this, but how difficult will it be to police it in future.
The USA health system is a nightmare of bureaucracy, trying to entangle what's gone on so far will be an epic task. Can it be monitored to stop it happening in future?

"The report recommends strengthening oversight of insurance coding practices, enhancing program integrity, and ensuring appropriate review of potentially improper billing practices. It also encourages continued evaluation of clinical practices and policies related to pediatric “gender medicine” and outlines recommendations intended to improve accountability across the healthcare system."

It's a politically partisan document, but the figures are still useful to have.

Just looking through the main report now. Don't know what some of these centres/centers are:

Contributors:

'Contributors
Aaron Baer, President, Center for Christian Virtue
Victoria Coley, Independent Women’s Forum
Neeraja Deshpande, Independent Women’s Forum
Eithan Haim, MD
Jordan Jantz, IW Features at Independent Women’s Forum
Aaron Kheriaty, MD, Ethics and Public Policy Center
May Mailman, Director, Independent Women’s Law Center
Andrea Mew, IW Features at Independent Women’s Forum
Rachel Morrison, Fellow, Ethics and Public Policy Center
Quentin Van Meter, MD'

https://en.wikipedia.org/wiki/Independent_Women%27s_Forum

https://www.ccv.org/

https://eppc.org/

Ethan Haim: https://www.nbcnews.com/nbc-out/out-news/justice-department-drops-case-texas-doctor-charged-leaking-trans-care-rcna189405

https://en.wikipedia.org/wiki/Quentin_Van_Meter

Crikey.

Politically partisan looks a bit different in the US!

Okay. This report has been produced by very politically partisan groups. Christian and conservative, and I think 'conservative' hits differently in the US. Not sure about Ethan Haim, lots of articles on him as a whistleblower.

Now into the body of the report.

'there is reason to believe that some (perhaps many) providers of sex-rejecting procedures systemically diagnose minors with physical conditions they did not have in order to secure insurance coverage for “treatments” (like breast
removal or hormonal treatment) that insurers (including Medicaid and Medicare) might not otherwise have covered had they been provided with full and accurate information. See Chapter 2. If true, the entities that took these steps face potentially serious criminal and civil liability.'

'What began as a handful of specialized clinics in the early 2010s grew into programs at over 225 hospitals and health systems nationwide by the early 2020s.
Financial incentives may explain at least some of this development. Pediatrics remains the lowes tpaid medical specialty, with average physician compensation significantly below that of surgical or procedural fields'

'The lifetime economic footprint for a single patient beginning these interventions as a minor is substantial even without surgery. According to the Human Rights Campaign, an organization that advocates for transgender healthcare, estimates place total costs between $25,000 and $75,000 over a lifetime. When surgeries are included, individual lifetime spending on surgical interventions
can easily exceed $100,000 and approach $170,000.13 These figures do not account for indirect costs such as fertility preservation (egg or sperm banking), voice therapy, hair removal, or later interventions for regret or complications—services that further embed the patient in the medical system. This dependency model mirrors chronic-disease management programs (e.g., diabetes,
HIV, or oncology), but unlike treatment for those diseases, sex-rejecting procedures start with physically healthy minors who would otherwise have generated negligible lifetime revenue.'

Oof.

'Watchdog analyses tracking billed charges for minors from 2019 onward estimate almost $120 million in total hospital and clinic billings nationwide, encompassing over 5,500 surgical procedures and 8,500 courses of hormones or blockers.14 Individual flagship programs have reported multimillion-dollar annual billings. For example, certain large children’s hospitals have seen gender-clinic revenue streams balloon in recent years. According to Do No
Harm, Mount Sinai Medical Center in NY and Boston Children’s Hospital are cited as the topgrossing providers nationwide, with over $8.2 million and $6.5 million respectively in total billed charges for such services to minors during the 2019–2023 period.15 This equates to well over $1 million per year across those five years. In an era of razor-thin pediatric margins and pressure on hospital reimbursements, this new patient cohort—young, insured or Medicaid-eligible, and requiring perpetual follow-ups—represented a strategic area of growth'

Chapter two is about the misuse of diagnostic codes:

'In a 2016 study titled “Identifying the Transgender Population in the Medicare Program,” CMS’s Office of Minority Health acknowledged that proxy diagnosis codes are being substituted for gender dysphoria.38 In the methods section, the authors explain that they included the ICD-9 diagnosis code for Unspecified Endocrine Disorder in their analysis because it is “frequently used by the transgender community to combat the perceived stigma of a GID diagnosis.”39 According to the paper, “among the most commonly used non-transgender-specific diagnosis codes is ICD-9 code 259.9 (Unspecified Endocrine
Disorder).”

A 2023 study from the University of Iowa Hospitals and Clinics, published in the Journal of American Medical Informatics Association suggests the same.41 The study analyzed diagnosis coding patterns in “gender-expansive” patients. To identify patients who were “gender-expansive,” the authors looked for, among other things, “ICD-10 codes related to gender dysphoria or unspecified
endocrine disorder.”42 Why look for patients with unspecified endocrine disorder? Because “the ICD-10 code E34.9 (endocrine disorder, unspecified)…was sometimes [used] instead of ICD-10 codes related to gender dysphoria.”

The authors never explain why this occurs, only that it occurs “sometimes.” But in fact, the study’s numbers show this code is used (misused, really) with great
frequency: the report’s numbers suggest that, of the 1,480 patients who were diagnosed with endocrine disorder, unspecified, only 71 patients (4.7%) had an actual endocrine condition.43'

I'm not sure how impactful the coding fraud will be. It seems shocking in the UK, but the US medicine and insurance industry is so screwed up that a lot of that sort of thing is pretty common.

I think the enforcement action by the current administration will have a huge chilling effect. We've already seen a lot of closures with previous administrative action. This will really compound things. But I don't think the report will make most people think the HCPs involved are unethical unless they've already cottoned on to how unethical this area of medicine is. Generally speaking, people in the US only want the government to be forcing insurance and HCPs to do what they ask, not to stop them.

I suspect that given the divisions, and trashing of US Government intervention in health policy, many will reject this as partisan fabrication.

https://www.hhs.gov/

Thanks for that perspective. Hard to guess how it would land from the UK.

But yes, I can see it being dismissed as politically motivated.

Still, contains useful links to evidence - some of which is from the pro-gender affirmation side, too.

Wouldn't the impact of fraudulent codes be taken up by insurance companies?

I'd imagine they would be less than delighted about having paid out for diagnoses that were effectively cooked up.

They might try and tighten up on it (maybe especially on the hormone treatment being coded as endocrine issues when it’s really gender dysphoria related, as that’s an ongoing expense) but I doubt gender “treatments” are where they’d save the most money trying to stamp out that sort of fraud, so probably not a priority?

But I do think the federal government going after HCPs and hospitals will have a huge chilling effect.