Ahead of the critical bill crossover deadline, the Maryland House of Delegates passed a bill Saturday morning that would allow trans, intersex, and other gender-diverse residents who qualify for Medicaid to obtain gender-affirming care through the program.

The Trans Health Equity Act would not create new standards of treatment; rather, it would enable residents without private insurance to obtain comparable gender-affirming care. The bill is now one step closer to the governor’s desk, where it will likely receive his signature, advocates have said.

On Friday, the bill was at the center of a nearly hourlong debate focused on an amendment proposed by Republican Del. Mark Fisher of Calvert County that would have barred gender-affirming care from being provided to qualified individuals younger than 18.

Fisher primarily took issue with the idea of minors receiving surgeries such as vaginectomies, mastectomies, and penectomies.

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“This is not about health. This is about male-to-female transition and female-to-male transition of children,” Fisher said.

Montgomery County Democrat Del. Bonnie Cullison, who served as floor leader during the debate, pushed back, saying, “This is absolutely about health.” The invasive surgeries Fisher mentioned would only be allowed “under extreme circumstances,” Cullison said, and like the rest of the provisions described in the bill, “when medically necessary and indicated for the health of the individual.”

Further, Cullison said, as stated in the bill, these and other gender-affirming health care decisions would only be done in consultation with “patient, parent, and the medical provider.”

Puberty blockers – reversible medications that can suspend some of the physical effects of puberty – were also at the center of the debate.

Fisher and others also voiced concerns over evidence that puberty blockers can lead to a loss of bone density. Cullison pointed out that many medications can lead to a loss of bone density, and said providers are aware of this risk and often prescribe supplements to counteract any deleterious effects.

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A second amendment to the bill, proposed on Friday by Frederick County Republican Del. April Miller, would have prohibited gender-affirming care to children without both custodial parents’ consent. It failed 91-36.

Patient age as it pertains to eligibility for coverage is not mentioned in the bill. And though Fisher’s amendment ultimately failed 90-37, children continued to be at the center of Saturday’s debate.

Del. Linda Foley, a Montgomery County Democrat, offered an anecdote on the floor about a former student who, at age 6, began dealing with gender dysphoria. After receiving counseling, the child began to live as a different gender and flourished emotionally.

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Bill sponsor Del. Anne Kaiser, a Montgomery County Democrat, said she has received questions about why she is so passionate about the legislation when she is not trans.

“Well, we don’t have representation in this House by anyone in the trans community. So myself and my 59 co-sponsors, we are your voice; we are your representation,” Kaiser said, “We recognize that what is being said nationally … about trans people are the same lies that were said about gays and lesbians 20 years ago, and that’s part of the reason I feel the passion and the connection to our trans brothers and sisters, our neighbors, our community.”

A similar version of the Trans Health Equity Act was previously introduced during the 2022 session. The only formative change is a reporting requirement, the intention of which is to help people who are enrolled in Medicaid know which gender-affirming care providers are in their network.

The move was influenced by an increase in harassment of gender-affirming-care providers nationwide.

Approximately 24,000 transgender adults live in Maryland, 6,000 of whom are enrolled in Medicaid, according to data compiled by the Williams Institute at UCLA.

In 2022, 98 individuals received gender-affirming treatment through Medicaid, according to a fiscal policy note on the Trans Health Equity Act.