Trump’s ‘Big Beautiful Bill’ Erases Trans People

On Monday, the Senate released its version of the so-called “Big, Beautiful Bill.” If passed, it would not only end Medicaid payments for “gender transition procedures” for people of all ages, but, like the House’s proposed legislation, will introduce some narrowly rigid definitions of “sex,” “female,” and “male.” 

The Senate finance committee’s summary of the bill lists this provision under the heading “Rooting out waste, fraud and abuse.” But transgender advocates, legal experts, and doctors see these definitions and proposed Medicaid cuts as part of the Trump administration’s ongoing campaign to demoralize and dehumanize trans individuals. 

“This is a blatant example of the continuation of Republican villainization of trans, non-binary, [and] intersex individuals,” says Kendall Martinez-Wright, government relations and policy associate for Treatment Action Group, an independent, community-based research and policy think tank committed to racial, gender, and LGBTQ+ equity.

Morissa Ladinsky, MD, a pediatrician providing gender-affirming care and a clinical professor at Stanford Medicine, says that the provisions in the bill would have wider implications. “The whole idea is to basically negate the validity of people whose gender identity doesn’t align with that 1750378369 well-defined biologic sex,” Ladinsky says. “It’s a definition that leaves no room for gender-diverse identities and medically indicated care for gender dysphoria.” In other words, these definitions only acknowledge biological sex, with no regard to gender identity. If passed, the reconciliation bill “will [codify] sex-based discrimination in the delivery of healthcare,” Ladinsky says. 

And it might not stop there: Experts fear that the definition of sex in the budget bills could serve as a blueprint for anti-trans policies extending beyond Medicaid, as well as those impacting other marginalized populations. “When we’re thinking about the rise of Christian nationalism, how long is it before someone says ‘If you can’t bear children, you are not a real woman,’ because the value of women is giving birth to children?” says Greene. Or, as Seran Gee, staff attorney at Advocates for Trans Equality puts it, “At best, [these definitions] create legal confusion. At worst, they lay groundwork for widespread discrimination.” 

What do the definitions say?

The House and Senate reconciliation bills stipulate that “sex” is “biologically determined,” and that “‘female’ means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization,” while “‘male’ means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization.” 

In other words, they “define sex relative to reproductive capacity” and ignore gender identity, Ladinsky says.

The definitions of “sex,” “female,” and “male” in these bills only apply in the context of who is able to access “specified gender transition procedures.” They go out of their way to indicate that Medicaid will cover various types of gender-affirming care for people, as long as they’re not transgender. 

“This is probably the most comprehensive encapsulation of defining sex, codifying it relative to reproductive capacity, and allowing space for an impressive array of conditions other than gender dysphoria, where these procedures and or medications remain medically necessary and indicated,” Ladinsky says. This includes chest procedures for people who were in a traumatic accident, and giving hormones to teenagers and adults who had pediatric cancer and underwent treatment that affected their reproductive system. It also covers procedures and treatments for people with differences of sex development, or intersex conditions.

So, are the representations of sex, female, and male in the bills medically accurate? 

“These definitions are coming from a position where genitalia and gender identity always match,” Ladinsky says. “That is exactly what they are trying to codify into law. In medicine, we recognize both sex and gender as different concepts, and different traits of a person. We teach gender identity as either aligned with or possibly different within an individual than sex.”

Definitions like the one in the Senate reconciliation bill aren’t new. In fact, they can be found in state laws across the country. Over the past few years, Independent Women’s Voice — a conservative, anti-trans, anti-abortion nonprofit — has been advocating for the adoption of definitions of sex based strictly on biology. They even provide model legislation for lawmakers to use, called the “Stand With Women Act.”  The sex definitions in the Senate bill were essentially copied and pasted from this template. 

Still, there’s some variation in the definitions on the state and federal levels, because when it comes to Republicans and sex, “no one can get on the same page coming up with the most exclusionary definition possible,” says Ben Greene, transgender advocate and the author of the book My Child Is Trans, Now What?: A Joy-Centered Approach to Support. As he points out, the definitions in the House and Senate reconciliation bills differ from the ones in Trump’s January executive order, and some statehouses’ anti-trans legislation. 

Ultimately, Greene says, the aim of the bill is to define sex in a way that makes sure it excludes every transgender person, but includes every possible other person. “They’re having a really hard time doing that, because like any other person, transgender people and non-transgender people all have really varied experiences of having a human body, of genitalia, of reproductive function or lack of functioning,” he explains. 

What does Medicaid have to do with this?

The bill would make it so that people would be unable to use Medicaid to pay for any procedures, treatments, or therapies related to gender dysphoria. This would be a major blow to the approximately 276,000 transgender adults enrolled in Medicaid.  

“We know that many transgender and nonbinary people rely on Medicaid for their health coverage,” says Heron Greenesmith, deputy director of policy at the Transgender Law Center.

“For our elected officials to prevent Medicaid from covering safe, trusted, life-saving health care is a cruel proposition that will have dangerous impact — which is emblematic of the administration’s cruel and harmful approach to restricting access to all people in an attempt to remove transgender people from their coverage.”

However, among the roughly 72 million Americans enrolled in Medicaid, transgender people who receive gender-affirming or transition-related healthcare represent a small minority. But given that Republicans have made anti-trans laws and policies a centerpiece of their platform, it’s easy to get the wrong impression. 

“With the over-focus on transgender people, they’re making a very heavy implication that [healthcare for trans people] is a waste of money,” Greene says. “They’re doing a lot of tremendously dangerous stuff, and dangling a shiny set of transgender keys in front of the American public to say, ‘look at how much these folks are taking your money,’ when this is largely a bill about concentration of wealth and destruction of public services.” 

Could these definitions serve as a blueprint for other laws and policies?

While the definitions are provided in the context of rolling back Medicaid coverage for trans healthcare, they are part of an overall strategy to chip away at LGBTQ+ civil rights, Martinez-Wright says. “Overall the definitions are a broad horizon — we’re talking about a snowball effect of a gray area where, in the future, certain definitions could delegitimize modern advances of science,” she says.

Ladinsky agrees. “Even though the definitions only apply to that narrow scope [of Medicaid], could they be used in the future for other purposes on a federal level? I fear that may be their intention,” she says. “I think it’s got broader intentions, [like] for legal documents, for government-issued identifications.”

The definitions of sex, female, and male aren’t out of place in Trump’s America. According to Gee, they “add a rigid, binary model of sex into federal law, echoing the ideological push we’ve seen in recent conservative efforts, including Trump’s 2025 executive orders.” 

Greene says that the fact that the bills are using these definitions to determine who does and does not receive healthcare should raise a red flag for people. “It’s very dangerous that they’re trying to redefine words to suit their political agenda, and that absolutely will not stop at transgender people,” Greene says, adding that the definition of “disability” could be next, for example. 

For now, the bill has not yet passed in the Senate. “We are in a space where now more than ever, individuals need to rise up and let [legislators] know that a continuation of this nonsense will have irreparable consequences,” Martinez-Wright says. 

Though this is a tough time for transgender people and parents of trans kids, Greene wants to remind people that “we never needed the government to allow us to be transgender,” and that advocates like himself will continue to oppose the Trump administration’s policies. “We will fight these definitions,” he says. “We know they are not accurate. We know that we live lives sometimes outside of how the government wants us to live, and that’s OK. We will continue to survive and continue to fight another day.”