Kamala Harris does not, in fact, want to do “transgender operations on illegal aliens in prison”—and that’s too bad.

In a 2019 ACLU survey, the current Democratic presidential nominee said she supported gender-affirming care for all trans adults, even those who were incarcerated in prisons or ICE facilities. After Donald Trump brought the topic up during September’s presidential debate, the ACLU’s Chase Strangio described this care as “a constitutional right”; The New York Times called Trump’s comments the “wildest sounding attack line that was basically true.”

Harris, meanwhile, seems to have walked back her 2019 stance, with her campaign telling Fox News, “That questionnaire is not what she is proposing or running on.” This is perhaps unsurprising: As a senator, Harris aggressively backed anti–sex work legislation like SESTA/FOSTA, and, in 2015, when she was California’s attorney general, her office pushed to deny incarcerated trans woman Michelle Norsworthy’s plea for gender-affirming care while she was being held in a men’s prison. (As MSNBC’s Katelyn Burns recalled, “Harris’ explanation was that she had fought internally within her department to support providing gender affirming care for prisoners, even as her office led the legal argument against providing such care.”) Trump may click-farm with hateful word salad, but the current Harris platform does not “specifically mention transgender people at all.” And as Democratic candidates have begun indulging in anti-trans rhetoric, Harris has stayed silent.

Which, for liberals, is ideal. Harris has positioned herself as Joe Biden but better, offering similar policies with zippier execution. But in addition to her technocratic zeal, there is another reason many liberals, both cis and trans, support Harris’s trans healthcare policies: because, as with Biden, and as with Trump, they are designed to benefit America’s trans bourgeoisie.

We can unpack this claim about transition and class via Rule 1557, the Affordable Care Act’s nondiscrimination clause. Prior to 1557, legal medical transition had mostly been restricted to white, bourgeois transsexuals, who, since the 1980s, have paid out of pocket. In the early 2000s, medical transition became increasingly available through private employer insurance, especially for white-collar employees of the American empire’s military and tech sectors.

The 2010 passage of the ACA changed this, but not on purpose. Rule 1557 did not propose new trans healthcare policies, or even describe existing ones (one of many reasons why Medicare for All has always been the floor, not the ceiling, of health justice struggles). Instead, nondiscrimination based on gender was interpreted in ways that forced “essential” aspects of medical transition to be covered by the federal government.

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In 2020, Trump narrowed the definition of Rule 1557 to exclude nondiscrimination based on gender and sexuality. If elected, he could easily do it again; he could also just dismantle the ACA entirely. Controlled demolition at the level of statecraft is, after all, the modus operandi of Project 2025, the Heritage Foundation’s “presidential transition” plan. But whether he gets rid of the ACA entirely or just narrows coverage, it’s clear that Trump will make moves on trans healthcare at the federal level.

Regardless of what Trump does to the ACA, however, white bourgeois trans people who can afford to pay out of pocket will still be able to transition medically. This is why we should not buy the liberal fearmongering rhetoric that Trump will send every trans person in America to detention facilities. He won’t. (We should instead focus on the already-existing detention centers being expanded in real time, from hyper-militarized ICE facilities across the US southern border to Sde Teiman, the Israeli “military base” that regularly subjects Palestinians to sexual violence, psychic humiliation, and physical torture—and where US officials have reportedly held daily meetings with Israeli counterparts in recent months.)

In contrast, Harris, like Biden, is unlikely to modify trans healthcare nationally. During the debate, Harris argued that we need to “maintain and grow the Affordable Care Act.” But, in typical Harris style, her plan for actually doing that is vague at best and noxious at worst. While she suggested capping insulin prices and continuing Biden’s policy of letting Medicare negotiate on drug prices, she also reaffirmed her plan, first introduced in 2019, to offer a private option, functionally blocking implementation of a full, federal healthcare policy.

Harris also has no strategy for countering the significant attacks on trans rights waged by state legislators or the Supreme Court. The court is currently preparing to hear oral arguments for L.W. v. Skrmetti, which challenges a Tennessee law “banning gender-affirming care for transgender people under 18,” and criminalizes any adults (teachers, parents) seen as “assisting” that transition. If passed, the case would prevent state-level anti-trans bills from being held up by injunctions, and could potentially pave the way for similar laws to be passed federally.

Regardless of who is elected, however, the system of private healthcare—which bourgeois trans patients access through employers and private wealth—will remain intact.

Thus, while Harris and Trump would treat trans healthcare differently, their policy choices—either directly or indirectly—would both result in a reversal of the population-level demographic shifts enabled by the ACA. Another way of saying this: While conservatives think trans people should not exist, and neoliberals think only “good” trans people should exist, these two blocs work together to shrink and gatekeep America’s existing trans population. This position, is, unfortunately, not new: The history of trans healthcare is also the history of the denial of that care to the vast majority of trans people.

The first major practitioner of trans care is often identified as Harry Benjamin, a German endocrinologist who began seeing trans patients in the middle of the 20th century. In 1966, he published The Transsexual Phenomenon, which soon became a landmark text in the field. While Benjamin was involved in youth medical transitions as early as 1941, it was only through funding from Reed Erickson, a rich trans man who had been his patient, that Benjamin was able to start a trans care foundation in the early 1960s, with an office on the Upper East Side. But most trans people couldn’t afford the costs of the care Benjamin was providing. Instead, his patients were mostly like Erickson: wealthy, white transsexuals.

In 1966, Johns Hopkins opened the first gender-affirming healthcare clinic in the United States, followed by other university research programs at schools like Stanford; while treatment programs were meant to be free or low-cost, this principle was applied inconsistently in ways that once again favored bourgeois white transsexuals. As Jules Gill-Peterson points out in Histories of the Transgender Child (2018), most Black, Indigenous or other people of color (BIPOC) trans children never even reached the trans clinic: Their gender dysphoria was typically misdiagnosed as schizophrenia or criminal deviance. White trans children were racialized as “plastic,” and thus capable of successfully changing sex, and, eventually, being recouped as normative American citizens.

This meager access was additionally stratified by class. In addition to battling bureaucratic wars of attrition to get HRT, white trans patients still had to pay for surgery out of pocket, as university gender clinics did not receive significant state or federal funding. The Johns Hopkins clinic, like the Harry Benjamin Foundation, instead received money from Erickson, whose interests and dwindling wealth had otherwise begun shifting to New Age mysticism. The Johns Hopkins clinic was subsequently shuttered in 1979.

By the 1980s, there were enough openly trans people for them to begin to act as a class, but that class, thanks to racial capitalism, was predominantly white and bourgeois. As Susan Stryker writes in Transgender History (2017), “It is often the most privileged elements of a population affected by a particular civil injustice or social oppression who have the opportunity to organize first. In organizing around the one thing that interferes with or complicates their privilege, their organizations tend to reproduce that very privilege.” In 1962, for example, pharmacologist Virginia Prince modeled the Foundation for Personality Expression, one of the first crossdressing organizations in the US, “on the college sorority system…which soon had chapters across the country.” By the early aughts, this class—whose members were now most likely to work in tech or the military—had achieved partial coverage through private employer insurance.

For trans people who were BIPOC and working-class, transition became both more precarious and, simultaneously, an important site of political struggle. Gill-Peterson has argued that DIY transition happens when trans people “don’t have access to a formal doctor, or don’t have the sanction of the law, and don’t have access to gender-affirming care. Probably the most widely known version of that is the self-administration of hormones without a prescription.” This gendered form of bodily autonomy was widely punished by the state. BIPOC trans women who did sex work were policed more aggressively; trans men doing DIY masculinization could be charged with criminal possession due to testosterone’s “controlled substance” status.

ACA Rule 1557 offered the first, albeit extremely limited, federal-level correction to this process: For the first time, more-marginalized trans populations could medically transition through publicly funded insurance at scale, causing the overall US trans population to become both significantly larger and more diverse. The demographic, political, and cultural implications of this cannot be overstated. Twenty fourteen might have been, as Time magazine called it, the “transgender tipping point,” but it was 2010 and Rule 1557 that arguably helped cause the tipping point to occur.

The nondiscrimination clause, like the ACA itself, is also quite limited. The question of “who can even access the clinic in the first place,” as Gill-Peterson reminded me over Zoom, “is inherently racialized.” This claim is borne out historically, through the legacies of men like Benjamin and Erickson, as well as through present-day statistics. A 2022 study showed that, while medical transition increased across all racial demographics, it expanded most significantly for white people; 731,200 white adults identified as transgender as of 2022, compared to 289,700 Latinx adults and 173,500 Black adults. Moreover, even though a 2024 Biden ruling confirmed that Rule 1557 included “gender identity,” a nationwide injunction has prevented it from even being implemented.

The anti-trans backlash which began during the first Trump presidency, continued during Biden, and which will continue under either Harris or Trump, must be understood as a revanchist attempt to roll back already meager trans healthcare gains.

Whether it is shaved down gradually or abolished all at once, diminishing state and federal trans healthcare funding is part of an effort to reduce and reverse the raced and classed demographic shifts enabled by ACA Rule 1557. While poor BIPOC trans people have insurance coverage stripped away from them, or are criminalized for DIY HRT injections, or are jailed for doing sex work, the trans bourgeois will continue accessing medical transition through private wealth and insurance from employers such as Lockheed Martin, Google, and Maersk.

Instead of collapsing into a “lesser of two evils” framework, the trans liberation movement should thus learn from the Palestinian liberation struggle and the fight to end the ongoing genocide in Gaza. Just as the movement for a free Palestine finds both candidates guilty of genocide, we should see liberal and conservative anti-transness, represented by both Harris and Trump, as two different levers of the same anti-trans machine.