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 that bans gender-affirming care for trans minors and censures any adults (such as teachers or parents) seen as “assisting” that transition. If the court decides in favor of Skrmetti, it 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 1948, 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; according to Gill-Peterson, 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 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. Gill-Peterson said that, 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 shared political—and, often, material—class. But, thanks to racial capitalism, that class 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, Gill-Peterson said.

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 Section 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, materially contributing to the significant growth in the size and diversity of the US trans population that was then taking place. 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 Section 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 clinics at all, as Gill-Peterson reminded me, “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. Trans people of color have a disproportionately harder time accessing care and often report lower quality healthcare due to medical racism.

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 Section 1557. Even if poor BIPOC trans people lose their insurance coverage, face potential criminal sanctions for DIY HRT injections, or are jailed for doing sex work, the trans bourgeois will continue accessing medical transition through private wealth or, if their plans cover it, employer insurance.

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.

Editor’s note, 10/28/24: The Nation does not have the resources to fact-check every web-only piece before publication. However, after this piece generated a strong reaction online, our fact-checking team examined it retroactively. We have updated it with the following clarifications and corrections.

The piece originally stated that Section 1557 did not purposefully prevent the discrimination of trans people. This has been updated to specify that it was not the statute’s explicit purpose. The piece stated that a Tennessee law criminalizes adults who help minors receive gender-affirming care; as a civil law, it would censure them. Due to an editing error, the piece incorrectly summarized the findings of a study on the demographics of the trans population in the US. The piece stated that trans people began to act “as a class” in the 1980s. This has been updated to clarify that they began to act as both a political and material class. In addition, the piece has been updated to clarify the role of health insurance, both private and public, in the growth of the trans population and in access to gender-affirming care.

We are ultimately responsible for, and regret, any errors. But we stand by the decision to publish this piece, do not think these updates nullify its core arguments, and fully support its author.