Lifelong Patients and Six-Figure Procedures: How Gender Transitions for Minors Became a Lucrative Business

A new report from the Department of Health and Human Services details the financial incentives behind the rapid expansion of pediatric gender programs, including nearly $120 million in billed charges for thousands of surgical and hormonal interventions between 2019 and 2023.

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The programs billed for more than 5,500 surgical procedures and 8,500 courses of hormones or puberty blockers over that time, according to the HHS , “Wolves in White Coats: How Doctors and Hospitals Pushed and Profited from the Fraud of ‘Gender Medicine.’”

The analysis, released Thursday, was commissioned to examine “insurance coding practices, perverse financial incentives, and the provision of sex-rejecting procedures for minors.”

From the early 2010s to the early 2020s, gender medicine exploded to include programs geared toward “gender dysphoria” in minors at more than 225 hospitals and health systems nationwide.

The treatments created “long-term revenue opportunities” for the clinics, the report says.

“Unlike most traditional pediatric services, which involve episodic or short‑term care, children receiving puberty blockers, cross-sex hormones, surgeries, and related services may require recurring endocrinology visits, laboratory monitoring, prescriptions, mental‑health services, surgical procedures, and follow‑up care extending into adulthood,” the report reads.

Cross-sex hormone therapy comes at an average yearly cost per patient of around $545 for androgens, $735 for estrogens, and $16,385 for the puberty-blocker GnRH. Meanwhile, surgical treatments, including mastectomies, mammoplasties, and phalloplasties, can range from $12,000 to over $130,000.

The lifetime cost of care for these patients can total anywhere from $25,000 to $75,000 — even without surgery, the report finds. Multiple surgical procedures can bring lifetime costs to as much as $170,000.

Mount Sinai Medical Center and Boston Children’s Hospital billed more than $8.2 million and $6.5 million, respectively, for such services to minors during the 2019–2023 period, according to an investigation by the medical watchdog group Do No Harm.

The report also details alleged efforts by hospitals to conceal from insurers the true nature of the gender-transition procedures they’re billing for in an effort to avoid running afoul of state and federal laws forbidding the procedures for minors.

Over a ten-year period beginning in 2015, public and private insurance was billed nearly $50 million for puberty-blocking drugs in patients ages 9 to 17 with endocrine disorder diagnoses, but no gender-related or precocious-puberty diagnoses. The report also identified nearly $11 million in puberty-blocker charges for hundreds of patients ages 13 to 17 whose claims carried a diagnosis of central precocious puberty. However, HHS notes that, 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.”

HHS warned that the claims data alone do not establish that every claim was improperly coded, saying the findings are “directional signals” requiring further verification. Nonetheless, HHS says the findings “strongly [suggest] a pattern of potentially fraudulent billing.”

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As the programs grew, activists encouraged providers to use diagnosis codes that HHS says did not accurately reflect patients’ underlying conditions in order to obtain insurance coverage for treatments that might have otherwise been ineligible for coverage.

In medicine, ICD-10 diagnosis codes are three- to seven-character alphanumeric codes that health-care providers use to designate diagnoses, injuries, and symptoms for medical billing and reporting. The report alleges that gender clinics may have used ICD-10 code E34.9 (“endocrine disorder, unspecified”) and the ICD-10 codes for central “precocious puberty” to conceal that the treatments were actually being used to treat “gender dysphoria.” 

As NR previously reported, prominent medical organizations have promoted the practice of miscoding sex-change procedures as routine endocrine care.

The controversial World Professional Association for Transgender Health (WPATH) encouraged providers in 2021 training materials to use “endocrine related” ICD-10 diagnosis codes for sex-change treatments, to ensure insurance reimbursement. (Three years later, the organization would come under fire after leaked internal documents revealed that its members had privately expressed doubts about the safety and efficacy of hormonal therapies and surgical procedures while continuing to advocate them publicly.)

Miscoding can allow providers to circumvent state and federal laws governing the use of Medicaid funding for hormonal therapies and surgical procedures that are intended to alleviate gender dysphoria in trans-identifying children and adolescents.

“By misrepresenting the medical procedures they are performing, providers can pass off transgender medicalization as, for example, routine endocrine care unrelated to pediatric medical transition,” Do No Harm previously warned. “These ‘loopholes’ may enable providers to get paid for procedures which otherwise may not be funded. In some cases, such practices may even be outright fraudulent or a means of evading state-level restrictions on child sex change interventions.”

Dr. Eithan Haim testified before Congress in April 2025 and warned lawmakers that providers were miscoding “gender-affirming” procedures.

Haim, who also exposed Texas Children’s Hospital’s secretive transgender procedures on minors, said insurance companies “don’t know that they’re getting defrauded.”

“This guide is essentially a template for how to commit medical fraud. We should all remember that this is something that people go to prison for. This is a major deal. They have entire departments and hospitals for this,” Haim told lawmakers of another guide produced by the Campaign for Southern Equality encouraging providers to miscode procedures.

Upon the release of the HHS report on Thursday, Vice President JD Vance and HHS Secretary Robert F. Kennedy Jr. dozens of hospitals and clinics identified by the report to the Department of Justice and the HHS Office of Inspector General for possible violations of federal law.

“Doctors and hospitals must put children’s health ahead of ideology and financial gain,” Kennedy said in a statement. “This report identifies troubling billing practices that demand scrutiny. HHS will follow the evidence, protect taxpayers, and hold accountable anyone who broke the law or violated the trust of patients and families. Under President Trump’s leadership, we are restoring transparency and integrity to American medicine.”

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