Co-authored by Tim Schwarzenberger, Director of Corporate Engagement
On August 11, 2026, the Centers for Medicare & Medicaid Services (CMS) did something the federal government had never done before. In a final rule taking effect October 13, 2026, it prohibited federal Medicaid and Children's Health Insurance Program (CHIP) dollars from paying for puberty blockers, cross-sex hormones, or surgeries intended to align a minor's body with a gender identity different from their sex. The rule, which labels these interventions "sex-rejecting procedures", caps a remarkable four-year reversal in how American law, medicine, and corporate benefit plans treat gender-transition care.
For most of the last decade, the trajectory ran the other direction. Gender-affirming care expanded rapidly through hospital systems, insurance plans, and Fortune 500 employee benefits, and public dissent from that expansion was frequently treated as bigotry. That consensus has now fractured, in the courts, in the medical literature, in Europe, and in corporate boardrooms. For faith-based investors, the shift is not merely a culture-war headline. It touches employee benefit design, healthcare and pharmaceutical holdings, hospital operators, insurers, and the corporate-activism posture of companies held in many diversified portfolios.
Modern gender-transition medicine in the United States is roughly seventy years old. It entered public consciousness in 1952–53, when Christine Jorgensen returned from surgery in Denmark to front-page coverage, and it was formalized largely through the work of endocrinologist Harry Benjamin, whose 1966 book The Transsexual Phenomenon gave the field its early framework. Johns Hopkins Hospital opened the first American academic Gender Identity Clinic in 1966, then closed it in 1979 after an internal study questioned whether surgery improved patients' lives, a controversy that pushed the practice to the margins of medicine for a generation.
The organization now known as the World Professional Association for Transgender Health (WPATH) published its first Standards of Care in 1979. In the 1990s and 2000s, clinicians in Amsterdam developed what became known as the "Dutch protocol," using puberty-suppressing drugs in adolescents followed by cross-sex hormones. In 2013, the American Psychiatric Association's DSM-5 replaced the diagnosis "gender identity disorder" with "gender dysphoria," reframing the condition around distress rather than identity itself (a move that would call into question the DSM’s adherence to scientific research over social ideology and has marked the field of psychology ever since).
Two developments accelerated access in the 2010s. First, the Affordable Care Act's nondiscrimination provision (Section 1557) was interpreted by the Obama administration in 2016 to require many insurers and providers to cover transition-related care, a position that has been litigated and revised repeatedly since. Second, pediatric gender clinics multiplied, and referrals rose sharply, particularly among adolescent girls, a demographic shift researchers still debate. A 2021 analysis by Reuters and the health-data firm Komodo found roughly 42,000 U.S. children and adolescents diagnosed with gender dysphoria that year, nearly triple the 2017 figure, with about 17,700 minors starting puberty blockers or hormones between 2017 and 2021.
In 2022, WPATH released its 8th edition Standards of Care. Notably, suggested minimum ages for hormones and surgeries that had appeared in draft versions were removed from the final document, a change that litigation in Alabama (Boe v. Marshall) later indicated followed pressure from a senior Biden-administration health official who was concerned the age thresholds would undercut legal arguments against state restrictions. That episode became central to a growing critique that the U.S. clinical consensus had been shaped as much by advocacy as by evidence.
Through the late 2010s and into 2021, large employers competed to expand transgender-inclusive benefits, a trend heavily driven by HRC's Corporate Equality Index, which rewards companies for covering hormones, surgeries, and related travel. Adding "trans-inclusive" plan design became a near-default for firms seeking a perfect CEI score, and corporate Pride marketing reached its high-water mark.
The inflection point most often cited is April 2023, when Anheuser-Busch's Bud Light brand sent a personalized can to transgender influencer Dylan Mulvaney. The sustained consumer boycott that followed (and the sharp, lasting sales decline) served as a warning to marketing departments across the country that visible alignment with transgender advocacy carried real commercial risk.
By 2025 and 2026, the retreat was broad. A Gravity Research survey found about 39% of corporate executives were scaling back public Pride engagement. Anheuser-Busch ended its sponsorship of St. Louis Pride after more than 30 years; major sponsors including Mastercard, Nissan, Comcast, Diageo, and Deloitte withdrew from Pride events in New York, San Francisco, and elsewhere, leaving several organizations with six-figure budget shortfalls. The Trump administration's January 2025 executive order directing agencies to discourage private-sector "DEI" programs added regulatory pressure to what was already a commercial recalculation.
The clearest single indicator is the collapse of the Corporate Equality Index itself. In the 2026 edition, released in February 2026, Fortune 500 participation fell 65% year over year. At least two dozen major employers, among them Walmart, McDonald's, Lowe's, Target, Nissan, Harley-Davidson, and Tractor Supply, publicly stepped away from the index. The same HRC report argues the drop reflects reduced disclosure rather than reduced coverage, and notes that roughly 72% of Fortune 500 companies still offer transgender-inclusive health benefits, though this claim is widely unsubstantiated one way or another and does not establish which procedures are covered for minor dependents.
That distinction, between what companies say and what their benefit plans pay for, is where the current fight has moved. In 2026, 1792 Exchange launched a campaign naming 550-plus companies whose employee health plans still cover gender-transition interventions for minor dependents, including Disney, Mattel, Sony Pictures, Lions Gate, and Wendy's. Some large employers have begun narrowing coverage: Charles Schwab, for instance, updated its plan to exclude transition procedures for minors.
At the same time, the medical-association landscape has grown more mixed. In early 2026, after CMS Administrator Mehmet Oz met with medical society leaders, the American Society of Plastic Surgeons called for delaying gender-transition surgery until age 19, and reports described at least one other major body softening its youth-care language. The American Medical Association and the American Academy of Pediatrics, however, publicly reaffirmed their support for gender-affirming care and framed the decisions as belonging to patients, families, and physicians rather than politicians. The corporate climate, in short, is no longer one-directional consensus; it is contested terrain in which companies face pressure from multiple directions at once.
Inspire Investing has made corporate engagement a central part of its response to this issue. During the 2026 proxy season, detransitioners shared their personal experiences directly with shareholders at the annual meetings of American Express, Home Depot, IBM, and Merck. Inspire also asked companies to conduct comprehensive reviews of employee healthcare plans covering gender-transition treatments for minors, including the potential medical, legal, regulatory, reputational, and financial risks.
Inspire then organized a coalition of investors and fiduciaries representing more than $100 billion in assets under management or advisement. The coalition identified 242 publicly traded companies whose policies and advocacy relationships may expose shareholders to unnecessary risks and called on them to reconsider divisive political activism and refocus on long-term shareholder value.
Most recently, on September 8, Inspire presented a shareholder proposal at Nike’s annual meeting calling for greater transparency regarding the business risks associated with the company’s political advocacy and charitable relationships. Nike illustrates the financial importance of this engagement. Its stock price has fallen approximately 78% from its all-time high, while its brand is estimated to be worth more than $33 billion, representing approximately 41% of its market capitalization. Nike’s political positions may not fully explain its financial decline, but a company facing challenges of this magnitude cannot afford to further divide its customers or treat brand politicization as cost-free.
Inspire prioritizes constructive dialogue while also using proxy voting and shareholder proposals when appropriate. That work has contributed to meaningful progress. Charles Schwab confirmed that its employee health plans no longer cover gender-transition surgical or pharmaceutical treatments for minors, while Walmart confirmed that its plans exclude gender-transition surgeries for minors. These outcomes demonstrate how informed and persistent shareholder engagement can encourage companies to adopt more cautious policies and better protect employees, families, brands, and long-term shareholder value.
The sharpest reversal has come in pediatric care, and it began in Europe. England's National Health Service commissioned an independent review led by pediatrician Dr. Hilary Cass; the final Cass Review, published in April 2024, concluded that the evidence base for puberty blockers and hormones in minors was "remarkably weak." NHS England stopped routine prescribing of puberty blockers for gender dysphoria in March 2024, and the UK enacted an indefinite ban on such prescriptions (NHS and private) in December 2024, to be reviewed in 2027. Sweden, Finland, and Norway had already moved earlier to restrict these interventions to research settings or exceptional cases.
In the United States, the Department of Health and Human Services released a 409-page evidence review, Treatment for Pediatric Gender Dysphoria, on May 1, 2025. It found the certainty of benefit to be "very low" and warned of long-term harms. Major U.S. medical associations disputed its methodology and framing, accusing the authors of cherry-picking studies. Six weeks later, in United States v. Skrmetti (June 18, 2025), the Supreme Court upheld Tennessee's ban on gender-transition procedures for minors by a 6–3 vote, holding that the law required only rational-basis review and did not constitute sex discrimination. Bans in roughly 27 states remained in force as a result.
The practical effect has been consolidation and closure. Children's Hospital Los Angeles, home to the largest public-insurance gender program for youth in the country, serving nearly 3,000 patients, closed its Center for Trans Youth in July 2025, citing federal funding threats and fiscal strain. Denver Health, Children's National in Washington, D.C., and other systems paused or ended pediatric services following the January 2025 executive order. Meanwhile, a wave of malpractice litigation from "detransitioners" (people who medically transitioned and later reversed course) has advanced. There are roughly 30 active cases; in February 2026 a jury returned a first-of-its-kind verdict awarding about $2 million to a detransitioner against her providers, and the widely publicized case of Chloe Cole against Kaiser Permanente is set for trial in 2027.
It is worth stating plainly what is not in dispute: gender dysphoria is a real and often severe form of distress, and the young people who experience it deserve genuine care and compassion. The dispute is over whether early medical intervention — with its irreversible elements and thin long-term evidence — is that care, or whether a more cautious, psychotherapy-first approach better serves them. On that question, the Western medical world, once seemingly settled, is now openly divided.
Federal action came in stages. On January 20, 2025, Executive Order 14168 directed the government to recognize only two sexes and to stop issuing passports with "X" markers. On January 27, Executive Order 14183 reinstated a ban on transgender military service. On January 28, Executive Order 14187, "Protecting Children from Chemical and Surgical Mutilation," directed federal agencies to condition research and education funding on hospitals and medical schools ending gender-transition procedures for patients under 19.
The Medicaid piece followed a deliberate sequence. In April 2025, CMS sent state Medicaid directors a letter urging scrutiny of the "quality of care" behind these services. In December 2025, CMS issued two proposed rules, one revising hospital conditions of participation, one addressing Medicaid and CHIP funds. The final rule, issued August 11, 2026, and effective October 13, 2026, bars federal Medicaid and CHIP matching dollars from covering puberty blockers, cross-sex hormones, or surgeries for gender transition for beneficiaries under 18 (under 19 for CHIP). Key features:
Two clarifications matter for accuracy. First, this rule targets minors; a separate mid-2025 HHS threat to withhold Medicare and Medicaid funding over adult gender care was shelved. Second, because Medicaid and CHIP cover a disproportionate share of low-income transgender youth, the rule's real-world effect on access is larger than the small patient numbers suggest; families in states unwilling to backfill with state funds will largely lose coverage (specifically for those who are in the middle of the process and might have biologically devastating consequences, beyond what the procedures have already done). So, while there is a cause to celebrate momentum in protecting minors from these horrifically life-altering programs, we also must grieve with those who will experience very personal collateral damage from the implementation and then removal of this access.
Scripture does not address puberty blockers or Medicaid rules, but it speaks with clarity to the questions underneath them: What is the human body? Who has authority over it? And how should God's people treat those who suffer?
The body is a gift, not a construction project. "So God created man in his own image, in the image of God he created him; male and female he created them" (Genesis 1:27). The Psalmist confesses, "For you formed my inward parts; you knitted me together in my mother's womb. I praise you, for I am fearfully and wonderfully made" (Psalm 139:13–14). Jesus himself grounds his teaching on marriage in the created order: "Have you not read that he who created them from the beginning made them male and female?" (Matthew 19:4). A biblical anthropology receives the sexed body as a true and good part of one's God-given identity, not a defect to be corrected by hormones and surgery, and not raw material for self-definition.
Our bodies are not our own. "You are not your own, for you were bought with a price. So glorify God in your body" (1 Corinthians 6:19–20). The modern claim that the self is authoritative over the body, what theologians have called "expressive individualism", runs against the grain of a faith in which even our bodies belong to Christ. As Abraham Kuyper's famous line insists, there is no square inch of human existence over which Christ does not cry "Mine!", and that includes the body.
The fall reaches our experience of ourselves. Romans 1 describes a humanity whose disordered desires and darkened understanding lead it away from the Creator's design. The Christian tradition has understood gender dysphoria not as a sin to be scolded but as one of the many ways a fallen world's brokenness is felt inwardly, genuine suffering that calls for genuine compassion, patient counsel, and prayer, while still holding that the path of healing does not run through remaking the body against its nature.
Compassion is not optional. The evangelical Nashville Statement (2017) affirms that it is possible "to speak the truth in love" on these questions, and Christian clinicians and scholars such as Mark Yarhouse and Preston Sprinkle have pressed the church to listen carefully to individual stories and to resist treating people as culture-war abstractions. Many who experience gender distress have been met by the church with ridicule rather than refuge. That is its own sin. A faithful response holds conviction and kindness together: clear about the goodness of God's design for male and female, and equally clear that every person wrestling with these questions bears the image of God and is someone for whom Christ died.
Similar to Pride Month, corporations have shown that they will gladly promote ideological messaging if it boosts their bottom line, but then quickly ignore these issues if the cultural tides turn in a different direction. This shows an obtuse lack of care for the very people they are stating to support.
This compassionate steadfastness is central to the work we do at Inspire. It is not our job to pass judgment on an individual, but to invest wisely in a manner that honors the plan for creation set by God at the beginning of time. It is the unwavering commitment to the heavenly-ordered instruction given through the Bible that actually sets us apart from the corporate response to ideological advocacy like transgenderism. Similar to Pride Month, corporations have shown that they will gladly promote ideological messaging if it boosts their bottom line, but then quickly ignore these issues if the cultural tides turn in a different direction. This shows an obtuse lack of care for the very people they are stating to support. While it is in the heart of many believers to see all the world value an individual’s body in the way it was originally created, Inspire strives to bring awareness to these issues so that companies would step away from these social endeavors that have hurt both those they are celebrating and those they are ostracizing.
The wise investor neither ignores this issue nor sensationalizes it. Companies revise benefit plans quietly; medical consensus shifts; laws change. Biblically responsible investing calls us to look past both the marketing and the outrage, to understand the substance of what a company funds and promotes, and to steward capital toward enterprises that honor the God who made us — fearfully and wonderfully — male and female.
"So God created man in his own image, in the image of God he created him; male and female he created them." — Genesis 1:27
"Whatever you do, work heartily, as for the Lord and not for men, knowing that from the Lord you will receive the inheritance as your reward. You are serving the Lord Christ." — Colossians 3:23–24
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Bringing ten years of experience as a professor at a Christian college, Chris is deeply rooted in faith-based values. He excels as a faith-based writer, adept at crafting financial curriculum with spiritual depth. In his role, Chris is responsible for sourcing and evaluating reliable sources to accurately screen companies and assign them an Inspire Impact Score. Furthermore, he meticulously curates screening categories to maintain clarity and alignment with Inspire's faith-based mission.
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