Oregon officials are set to require health insurers, both public and private, to cover procedures like sex-change surgeries and cross-sex hormones for all ages. Those that fail to do so risk losing their state licenses.

The proposed rule from Oregon's Department of Consumer and Business Services relies on the latest standards of care developed by the World Professional Association for Transgender Health (WPATH), which called transgender genital surgeries and other procedures "medically necessary" to justify expanding insurance coverage.

The policy change stems from a 2023 law that made Oregon one of several so-called trans sanctuaries, guaranteeing that minors could receive puberty blockers and chemical or surgical sex changes. The rule, set to take effect next year, dictates "what insurance companies are required to cover and how they provide that coverage," according to Department of Consumer and Business Services spokesman Mark Peterson.

While Oregon won’t be the first state to require insurers to cover gender procedures, it will be the among the first to cite, on its own accord, WPATH's latest standards of care in a statewide rule.

Those standards outline "medically necessary" interventions, including electrolysis, facial feminization surgery, and tracheal shaves—all of which are typically considered cosmetic—as well as genital surgeries, double mastectomies, and even "eunuch" and "nonbinary" procedures to create androgynous bodies. WPATH's standards have been cited in lawsuits meant to compel states, including Georgia, to include sex-change operations in public benefit plans. Oregon's rule, however, pertains to the state's insurance regulation process, which covers both public and private entities.

WPATH’s decision to describe transgender surgeries as "medically necessary gender-affirming health care," meanwhile, stemmed from legal and financial pressures, not medical evidence, the Washington Free Beacon reported in July. That language was specifically included to expand insurance coverage and give doctors more freedom to prescribe gender interventions, WPATH members said in documents revealed through court filings.

Oregon’s proposed rule also requires insurers to contract with enough gender doctors to prevent long wait times. It doesn’t, however, mention detransitioners, who struggle to get carriers to pay for reversal treatments. Meanwhile, the health plans’ employees responsible for denying claims have to take WPATH’s own training, or a comparable version, to "demonstrate their experience with gender-affirming treatment."

"If Oregon wants to put the safety and welfare of its so-called transgender citizens at risk while passing a nondiscrimination clause, they’re doing a bang-up job of it," Heritage Foundation senior legal fellow Sarah Parshall Perry said. "What they’re doing right now is very likely to result in an incredibly litigious phase for the attorney general of Oregon."

State officials unveiled the rule Oct. 30, and the public has until Tuesday to weigh in before it takes effect Jan. 1.

At a Nov. 19 hearing before the Oregon Department of Consumer and Business Services, trans activists and medical practitioners praised the state regulators’ move as removing barriers to procedures they say are necessary for their happiness.

"While I would love to pay for my care out of pocket, the reality is that transitioning has made it harder for me to find work and harder for me to make money," said Katherine Goforth, a biological male identifying as a woman who’s been been waiting since 2018 for surgeries after starting hormonal transition.

"Waiting and waiting and waiting is agony for me," the opera singer and classical music professor added. "The more I have to wait, the more society has to wait for all the things I have to contribute."

Critics included Camille Kiefel, a detransitioner who helps others trying to return to living as their birth sex, who said WPATH has not responded to her overtures for a dialogue. Kiefel described one male detransitioner who removed his genitals while initially changing genders, causing him chronic health issues. She said doctors forced him to keep taking estrogen since he couldn’t produce testosterone.

"When you mention detransition to your physician, it automatically brings up WPATH guidelines, which makes them hesitant to intervene," Kiefel said.

Jamie Reed, a former gender clinic caseworker who became a whistleblower on the industry, testified that her former employer’s reliance on WPATH’s standards led to "excessive numbers of young people being physically and mentally harmed." Gay kids who don’t conform to gender norms—such as effeminate boys—are most at risk that they’ll receive procedures without proper assessment, she said.

"I counseled minors who had irreversible harms from these interventions, including young people having such severe vaginal lacerations due to the early use of testosterone that they required emergency surgical repair," said Reed, who serves as the executive director of LGBT Courage Coalition, a group that opposes gender transitions for minors.

Oregon’s proposal comes as WPATH and its guidelines face mounting scrutiny. The group is increasingly seen as putting activism over medical credibility, with even mainstream outlets like the Economist reporting on its alleged research manipulation. WPATH also suppressed its own commissioned research about transitioning minors when it failed to show promised benefits, internal emails released in court filings show. And under pressure from President Joe Biden’s transgender health official, the group lifted age limits from its standards of care.

According to a briefing for an upcoming Supreme Court case on Tennessee’s ban on youth transgender procedures, the authors of WPATH’s standards of care "opted to conduct no systematic evidence reviews precisely because doing so would ‘reveal little or no evidence and put us in an untenable position in terms of affecting policy or winning lawsuits.’"

WPATH’s standards of care also outlines procedures beyond transgender interventions, as well. It includes a chapter on eunuchs, for example, described as "individuals assigned male at birth" who "wish to eliminate masculine physical features, masculine genitals, or genital functioning."

If the proposed rule is finalized, Oregon—which has performed nearly 850 sex change procedures on minors since 2019, according to the medical ethics group Do No Harm—could raise the stakes for other blue states that champion gender ideology, particularly in light of President-elect Donald Trump’s election victory.

"We’re going to see a bonanza of really bad bills," said Erin Friday, a California attorney and co-lead of Our Duty, an activist group for parents of gender-confused kids. Advocates "want to set it up to be very similar to abortion, so it will be a state-by-state effort to counteract what Trump is attempting to do."

In 2023, Trump announced his plan to "protect children from left-wing gender insanity" with executive orders to end programs promoting gender transitions, stop taxpayer dollars from funding sex trait modification procedures, and to ban these procedures for children nationwide. In response, prominent Democrats have vowed to counter Trump’s proposed measures.

Gov. J.B. Pritzker (Ill.), for example, boasted about his state's laws surrounding transgender procedures.

"This Transgender Awareness Week, I want you to know that I see you and have your back as governor," the Democrat posted to X on Nov. 16. "Illinois has enshrined protections for gender-affirming care to meet this moment—and because of that, you will have a home here always."

The governor’s transgender cousin, Jennifer Pritzker, has funded WPATH through her nonprofit. Other Pritzker family members, which inherited the Hyatt hotel fortune, have also donated to gender clinics and legal causes.