On Wednesday, nine trans youth organizers were arrested in the lobby of the Massachusetts Attorney General’s office. They had walked in carrying hormone gels, pills, sharps containers, and a demand — that Attorney General Andrea Campbell enforce the state’s civil rights laws against the hospitals that have spent the last ten months quietly ending gender-affirming care for trans youth in the Commonwealth. By the time Campbell’s office handed them a phone offering a meeting — a meeting organizers had sought for months without result — they had already been in the building for hours. They refused. State troopers arrested nine of them. The office told the Guardian it had no role in the arrest decision.
The protest was a specific act. The structural pattern it named is this column’s subject.
Three of Massachusetts’s largest healthcare systems have ended gender-affirming care programs for patients under 19 since October of last year. Fenway Health — the institution founded in the early 1970s as a community-health drop-in for gay clients, the place where the first AIDS diagnosis in New England was made, the institution that built a half-century of queer medicine on the principle that patients come first — stopped providing hormone care and puberty blockers to anyone under 19 in October. Outer Cape Health Services, which runs three facilities on Cape Cod, followed. Baystate Health, which serves western Massachusetts, followed. A fourth Massachusetts hospital canceled gender-affirming surgery appointments for adult trans women, even though no federal order touched adult care. Massachusetts has shield laws. Massachusetts has a state civil rights law that the Attorney General’s office has itself said may have been violated. Massachusetts has, on paper, the legal architecture to prevent what is happening. It is happening anyway.
The column is about why.
What is happening can be stated in one sentence. The Trump administration’s January 2025 executive order threatened to cut off federal funding to any hospital that provided gender-affirming care to trans youth. The follow-on effort by Health Secretary Robert F. Kennedy Jr. to target Medicaid funding to those hospitals was tossed in court. The Guardian reports there are no documented cases of any hospital losing federal funding for providing this care. The federal threat is, as of this writing, inoperative in the way that matters to Massachusetts hospitals’ bottom lines. Three of the state’s largest healthcare systems have nonetheless treated the inoperative threat as operative, ended care for trans youth, and the state’s chief law enforcement officer has declined to use the tools she has to require them to do otherwise.
That is the structural fact. It does not require conspiracy theorizing. It requires reading the documentary record the institutions have themselves produced.
The cui bono trace is worth laying out plainly, because both sides in this debate — the AG’s office framing the situation as contained, the activist organizations framing it as abandonment — have an interest in obscuring parts of it.
First-order beneficiaries: the three (and counting) hospital systems that have relieved themselves of the cost — political and legal, not primarily clinical — of continuing to provide this care. Fenway’s particular surrender is the one that should land hardest. The institution exists because queer Massachusetts demanded that it exist. Its decision to drop trans youth care to a Trump executive order that has no operative enforcement behind it is not a clinical judgment. It is a preemptive surrender to anticipated political pressure. It is the institution asking itself how much federal money it might lose and answering the question by abandoning patients whose federal money was never at risk.
Second-order beneficiaries: the broader apparatus of the Trump administration’s anti-trans political project, which gets to claim Massachusetts as successful terrain without ever having to win the legal case it filed. Even the federal enforcement that has been operationally successful — the appeals court clearing the DOJ’s subpoena of NYU Langone’s records — does not require Massachusetts hospitals to end care. The subpoena is a record-production order against a New York institution, not a funding cutoff. The Massachusetts hospitals are reading threat where threat has not yet materialized in their specific case. That is exactly the institutional response the architects of the executive order were hoping for. The point of an order is not always its enforcement. Sometimes the point is the rearrangement it provokes in advance of enforcement. The hospitals have done the administration’s work for it.
Cost-bearers: trans youth and their families, named and unnamed. Josh, eighteen, born at Fenway to lesbian parents, who started hormone replacement therapy in middle school and had to restart the intake process at Boston Children’s after Fenway walked away — a process that took over a year. Safara Malone, a Harvard senior who moved to Massachusetts from Texas in 2024 precisely because Texas had made her existence criminal, who is now considering leaving the country because the state she chose for safety is no longer safe. The unnamed dozens Teddy Walker of Protect Trans Futures says he knows. The families in western Massachusetts for whom Ali Wicks-Lim says there is no remaining provider within reasonable distance. The parents, grandparents, and caregivers whose decisions about their children’s bodies are being made for them, by hospital counsel anticipating threats that have not materialized.
Nowhere in this chain does the harm disappear into abstraction. It lands on individual young people whose medical continuity has been broken. It lands on families who made decisions about where to live based on what the law in those states said — and who are discovering, ten months in, that the law was not the binding constraint.
Which brings the column to Attorney General Campbell. The structural question is not whether she sympathizes with trans youth. She plainly does. She met with advocates in April. She has repeatedly said trans healthcare “remains legal and protected” in Massachusetts. She joined 21 other state attorneys general this week in suing the Trump administration over its attempt to block Medicaid coverage for youth gender-affirming care. None of this is in dispute. None of it has produced what the column is about.
Her office’s argument to the Guardian is twofold. First, that the actions taken by attorneys general in California and New York — suing or ordering hospitals to resume care — would not produce different outcomes in Massachusetts. Second, that “the cessation of gender-affirming care for minors by Fenway Health, Outer Cape Health Services and Baystate Health has not resulted in a wave of hospitals or clinics ceasing to provide care in the Commonwealth.” Her office has asked Protect Trans Futures to connect them with families who have lost care. The group says it has already done this, multiple times, and nothing has come of it.
Both arguments are intelligible. Both are inadequate in the way that, structurally, inadequate answers to structural failures always are.
The argument that three hospitals’ surrender does not constitute a “wave” is the argument that the third domino is not yet a wave. It is an argument from the absence of catastrophe rather than from the presence of remedy. The argument that California-style enforcement would not produce California-style results may even be true. It does not follow that no enforcement action of any kind is possible. It follows only that the office has not tried — and that the office has not been pressed, by any institutional force it answers to, to try.
Massachusetts has shield laws. Massachusetts has state civil rights law. Massachusetts has, on paper, the legal architecture to make a hospital that ends care because of a federal threat the subject of an investigation and, if the facts warrant, litigation. The state Attorney General is the officer charged with that work. The office’s own statement — that the cessation of care “may amount to discrimination” under state law — describes the predicate for action. The office has identified the legal theory. The office has declined to deploy it.
This is the structural pattern the column exists to surface. The hospitals are doing the administration’s enforcement work for it. The Attorney General’s office is declining to do the state’s counter-enforcement work. The result is the end of care for trans youth in a Commonwealth that has every legal instrument needed to prevent it. No individual actor in this chain intended that outcome. Each actor made a defensible-seeming decision within a frame that obscured the cumulative effect. The cumulative effect is the point. The column names it.
There is a temptation, in this register, to soften the indictment with reference to the difficulty of the political moment, the genuine fear hospitals operate under, the limits of what any single office can do against a hostile federal government. The column refuses the temptation. Difficulty is real. Difficulty is not exoneration. The hospitals have a fiduciary duty to the trans youth in their care; that duty does not pause for federal threats that have not materialized. The Attorney General has a sworn duty to enforce state law; that duty does not pause because the targets of enforcement are large institutions that would prefer not to be targeted. The political moment is what it is. The duties exist within the moment. The duties are not diminished by it.
The medical consensus on trans youth care is, by every major American medical association’s count, settled: care demonstrably reduces suicide risk and mental-health harms. The political apparatus has nonetheless constructed an appearance of legitimate medical dispute in which none exists. The Oreskes-and-Conway pattern — the deliberate construction of the appearance of legitimate scientific disagreement where the evidentiary position is one of substantial consensus — is at work here. A majority of American medical experts support trans youth care, and the broader anti-trans movement has been running that constructed dispute for years to justify hospital capitulation. The Guardian’s own framing concedes the point. A majority. The manufactured dispute is what the column names: a manufactured dispute, full stop.
Let the column say what the structure has been saying.
King saw this at Riverside Church in April 1967, when he named his own government “the greatest purveyor of violence in the world today.” His late structural critique ran on one recognition: institutional compliance with anticipated injustice is the mechanism by which the injustice is delivered. He saw it in the northern liberal who counseled patience. He saw it in the labor leader who urged workers to wait. He saw respectability function as a delivery mechanism for the policy the respectable claimed to oppose. King’s argument, at its most structurally precise, was that the worst outcomes do not always arrive by frontal assault. They arrive by the quiet institutional decisions of people who know better and act as if they did not.
The hospitals know better. The Attorney General knows better. The trans youth know that the institutions know better. The column is for the trans youth.
There is a hard floor to this column’s register, and it lives here. By any means necessary that operates within the political and legal instruments this column has spent its life arguing for — by litigation, by organizing, by sustained public pressure that names institutional cowardice for what it is — the care that Massachusetts law still protects must be the care Massachusetts delivers. The arc of the moral universe is long, King said. It bends toward justice. The arc, however, does not bend on its own. It bends when specific institutions, in specific moments, under specific pressure, decide to stop cooperating with the machinery of injustice and start enforcing the law they swore to uphold.
Three hospitals have decided to stop enforcing their duty to these patients. The Attorney General’s office has decided to stop enforcing the state’s civil rights law against those hospitals. The trans youth and their families have not stopped anything. They are the population the column exists to defend. They are the population Massachusetts’s institutional architecture is currently failing.
The work is to make the institutions do what they have already decided, on paper, to do.