A cadre of pro-transgender nonprofits is systematically evading laws in 27 states that protect minors from transgender procedures, according to a recent investigation by Manhattan Institute’s Christina Buttons. Since 2023, organizations like the North Carolina-based Campaign for Southern Equality (CSE) have rapidly expanded their efforts to coordinate providers and pay for appointments and travel from pro-biology states. According to Buttons, “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.”

The investigator posed as a Nashville mother of an 11-year-old girl who “had recently begun identifying as nonbinary and used both they/them and she/her pronouns,” she explained. “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.”

Buttons filled out an application on CSE’s website, received an email response, and spoke with one of CSE’s “care navigators” over the phone. When Buttons raised the topic of puberty blockers as a potential “pause button on puberty,” the care navigator affirmed that characterization as “exactly correct,” praised her for doing her research, and said 11 was a good age to begin treatment.

One purpose of the exercise was to demonstrate what low (or even non-existent) barriers exist to surreptitiously obtain transgender hormones for minors in states that prohibit such procedures. Even the medical organizations most responsible for pushing “gender-affirming care” would not recommend a child commence puberty blockers before reaching Tanner Stage Two, the first visible signs of puberty. But this would require an actual physical assessment; CSE’s representative affirmed the child’s readiness in a single phone call with the parent, merely by inference based on the child’s age.

Thus, the effort to evade state prohibitions on transgender procedures for minors is analogous to the effort to evade state abortion prohibitions by illegally shipping abortion-inducing pills through the mail. CSE is certainly violating the spirit of state laws, even when it believes it manages to hold to the letter.

The “care navigator” informed Buttons that CSE “monitors changing state laws daily” — evidently for the purpose of exploiting loopholes. “The prescribing of that medication is not illegal,” the representative claimed. “It is the prescribing for gender dysphoria from a local doctor that would not be okay.” However, she assured Buttons that “a lot of folks are able to get the meds locally,” either through local pharmacies or through the mail from out-of-state.

CSE provided Buttons with multiple options for out-of-state providers of transgender procedures for minors. Since Buttons was posing as a mom based in Nashville, she received recommendations for centers in Illinois, Michigan, and Georgia (Georgia law prohibits cross-sex hormones and transgender surgeries for minors, but it does not prohibit puberty blockers).

An unnamed collaborator working with Buttons contacted CSE posing as an Idaho parent of a 16-year-old. That collaborator was given recommendations in Oregon and California. Thus, CSE maintains a nationwide network that can tailor out-of-state recommendations based on where a person lives.

But CSE does more than provide recommendations. The CSE representative told Buttons that she could request a $500 travel grant after scheduling an appointment; CSE provides grants in advance, which are 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 was told. The representative who spoke with the Idaho collaborator offered to send the travel grant before an appointment was even scheduled. “We ask that it’s used for travel, but we do not require any receipts,” she said.

Even after covering travel arrangements, CSE still has money in its pocket that’s just itching to promote transgender procedures for minors. CSE first recommended Buttons contact Outpatient Family Medicine Transformed, the private practice of Dr. Jessica Lapinski in Bloomingdale, Ill. Upon contacting the practice, Buttons learned that minors seeking transgender services would have to pay a monthly membership fee of $170, not counting labs or meds. However, an employee told her that CSE could cover the full year of membership fees.

According to Buttons, CSE director Allison Scott claimed earlier this year that the CSE’s Trans Youth Emergency Project had distributed approximately $1 million in travel grants and more than $1 million to “frontline partners working directly with trans youth.”

Despite the hefty price tag, Buttons found that the Bloomingdale center had a long wait list — perhaps due to organizations like CSE subsidizing its services. But CSE was not deterred. They also informed her about Main Line Health in Pennsylvania, WMed Health Family Medicine - Crosstown Clinic in Kalamazoo, Mich., Olive Tree Health Direct in Wixom, Mich., Fitchburg Family Clinic in Wisconsin, Endocrine Kids in Michigan, Harmony HRT and Elevated Community Health in Colorado, and Family Tree Clinic in Minnesota. The Idaho collaborator was told about Oregon Health & Science University’s Doernbecher Children’s Hospital and the UCSF Child and Adolescent Gender Center.

A notable pattern with these transgender centers was their willingness to file whatever documents were necessary to get the transgender drugs to children, Buttons noticed. Most medications used for transitioning children do have legitimate uses as well, and state laws only prohibit their use for the specific purpose of assisting with an attempted gender transition. That makes fraud harder to spot, although states like Texas have gone to great lengths to do so.

The Bloomington location told Buttons they “used a general ‘endocrine disorder’ diagnosis code for labs and medications” so the treatments would not get flagged as being for gender dysphoria. The center had its own in-house pharmacy, but it also worked with specialty pharmacies that “could mail estradiol and testosterone vials directly to my home or send prescriptions to my local pharmacy,” she wrote.

In a follow-up call with her CSE representative, Buttons mentioned the practice of miscoding transgender drugs with the endocrine disorder diagnosis. The representative “expressed no concern about the coding practice,” she said. Indeed, Do No Harm previously warned that CSE specifically recommended this practice.

Main Line Health also told Buttons the transgender prescriptions could be mailed directly to her home or sent to pharmacies in Tennessee. They only required one in-person appointment per year, with follow-up appointments conducted virtually from Tennessee. A representative told Buttons that her boss knew “all the different tricks” for using diagnostic codes that “don’t specifically say anything about gender.”

Other transgender providers gave similar answers with greater or lesser degrees of vagueness. The common patterns were: a willingness to fudge the insurance codes, a system for shipping the drugs across state lines or sending the prescriptions to out-of-state pharmacies, and a flexibility with where clients took virtual appointments.

The best example of that last item in Buttons’ report was QueerMed, listed on CSE as a virtual hormone provider. As Buttons explained its process, “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.” They would ship the medication to the family’s home address and instruct the family how to administer the hormone injection at home. However, the representative admitted that QueerMed had no way to verify that the client had ever crossed state lines, and it did not require clients to provide proof of their location.

Telehealth across state lines is conceivably subject to the laws of the state in which the client is located.

However, not every provider Buttons investigated had the same loose policies. One CSE-recommended provider, Cedars-Sinai’s Pediatric and Adolescent Gender Wellness Clinic in Los Angeles, was willing to treat out-of-state patients” but “required them to attend appointments and pick up prescriptions in California.” Several others followed the same policy.

In other words, the evidence Buttons found pointed to a patchwork situation, in which neighboring states had opposite policies. Some states prohibited transgender procedures for minors, while other states had no regulation at all, allowing providers to offer whatever cross-border services they saw fit. Some providers chose to comply with all relevant laws as strictly as possible, while others showed an affinity for bending the rules to the breaking point.

This patchwork situation demonstrates the ongoing relevance of state and local elections to the debate over transgender procedures for minors. Much like the Dobbs decision for abortion, the Supreme Court’s Skrmetti decision did not settle the issue so much as affirm that the issue must be settled in the political sphere. The extensive efforts by pro-transgender nonprofits to skirt the rules suggest that the issue is not settled.

Even a state that has passed a law protecting minors from gender transition procedures could see a future legislature repeal it, or (as happened in Arizona) a future governor neuter it. States like Colorado and Illinois — progressive bastions in the Heartland — have already become hubs for this cross-border traffic. Pro-transgender forces would love nothing better than to win new beachheads in deeply conservative regions, with states that are not quite out of their reach, electorally — states like Georgia, Louisiana, and Kansas come to mind.

Buttons found that CSE is already receiving substantial backing from deep-pocketed leftist donors. In 2024, it reported nearly $3 million in revenue from donors including MacKenzie Scott (ex-wife of Jeff Bezos), the Arcus Foundation, the Chicago Community Trust, the Ford Foundation, Oak Foundation, Tides Foundation, and Proteus Fund. Its network is still mobilizing, so its cash flow has not yet surpassed the Amazon River. But one imagines that, with such backers, CSE will always have as much money as it requires for its purposes.

Indeed, many of the same donors are also involved in political affairs, and they could decide it is a good investment to pour millions of dollars into state campaigns to reverse the hard-won efforts to protect children from transgender procedures. Because this threat is always possible, state elections will always remain important to protecting children.