Christina Buttons told the gender clinics she was a mom in Nashville. Her 11-year-old daughter had just announced she was nonbinary. There was no history of gender confusion and no years of struggle. The girl had made the announcement recently.
Tennessee banned puberty blockers and cross-sex hormones for minors in 2023. Buttons wanted to know whether that ban actually stopped anyone.
It doesn't. Clinic after clinic told her how to get around it.
Buttons, an investigative reporter for City Journal, started with the Campaign for Southern Equality. It's a North Carolina activist group that runs a program called the Trans Youth Emergency Project. The program exists to get kids in the 27 states with bans to doctors who will treat them anyway. It works with more than 130 partners and has handed out more than $1 million in travel grants to over 1,200 families.
A navigator named Amanda offered Buttons $500 per trip, up to four trips a year. Another navigator told her the program doesn't ask for receipts.
Then Amanda explained why the Tennessee law isn't really a problem. "The thing is that the prescribing of that medication is not illegal," she said. It only becomes a problem if a local doctor writes it up as treatment for gender dysphoria. "There are all sorts of ways to access," she said.
The clinics spelled out what those ways are.
At Main Line Health in suburban Philadelphia, a nurse told Buttons that one of their providers knew "all the different tricks." One trick is billing codes that "don't specifically say anything about gender." When Buttons asked whether that meant an endocrine disorder code, the nurse agreed. The plan was one in-person visit a year in Pennsylvania, with everything else done by video from Tennessee. The prescriptions could go to a Tennessee pharmacy or arrive by mail.
Outpatient Family Medicine Transformed, a clinic outside Chicago, charges kids $170 a month. A staffer said the Campaign for Southern Equality could cover the whole year. The clinic keeps puberty blockers in its own in-house pharmacy and works with specialty pharmacies that mail estrogen and testosterone straight to the family's home. For the labs and prescriptions, it uses an "endocrine disorder" code. That way, the staffer explained, the pharmacy never learns what the drugs are for. The clinic has a waiting list of about 70 children.
Oregon Health & Science University is a taxpayer-funded public university. A staffer there called an alternative diagnosis "one possible avenue," depending on the insurance.
The telehealth company QueerMed went further. Its office manager told Buttons that the girl could do her video visits from the car at a rest stop across the state line. The medication could then be shipped to Tennessee. The office manager said staff can't see where patients are, and patients don't have to prove it. After Buttons' story ran, QueerMed's founder said the company "does not mail medications to anyone" and verifies every patient's location at every visit. That was not what Buttons was told on the phone.
Buttons asked the Campaign for Southern Equality to respond. The group's executive director, Jasmine Beach-Ferrara, did not reply.
Using an endocrine disorder code is the core of the scheme, and federal investigators are calling it fraud. An 11-year-old girl who thinks she might be nonbinary doesn't have an endocrine disorder. Billing an insurer, or Medicaid, as if she does gets the claim paid and keeps the pharmacist from asking questions. It also leaves her medical record false for the rest of her life.
The Trump administration has already referred dozens of hospitals and clinics to the Justice Department over this exact kind of billing. Rhode Island Hospital handed over more than 112,000 pages of records on minors under a DOJ subpoena. A Democrat-appointed federal judge in Rhode Island blocked investigators from reading them, and a federal court in Texas has since ordered the records turned over to the judge for private review.
Dr. Eithan Haim exposed the gender program at Texas Children's Hospital. He has reviewed detransitioners' records and says doctors used "proxy diagnosis codes" as a "false pretext to secure insurance payment for hormones and surgery." On the records DOJ is now collecting, his verdict was: "The evidence of misconduct is astonishing."
There's already a price for some of it. Detransitioner Fox Varian won a $2 million malpractice verdict against the providers who removed her breasts as a teenager. According to Haim, her chart listed "breast hypertrophy," a diagnosis for oversized breasts, instead of gender dysphoria. And Texas Children's, under a settlement with the Justice Department, just opened the country's first clinic for patients who want to reverse their transitions.
Tennessee's legislature passed a law to protect kids. An activist group with a seven-figure travel budget built a network to get around it, and the clinics in that network explained how on the phone to a woman they thought was a worried mom.