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 columnist 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 Section 1557, the Affordable Care Act’s nondiscrimination clause. According to Jules Gill-Peterson, an associate professor at Johns Hopkins University who specializes in trans history, legal medical transition had, before Section 1557 was enacted, mostly been restricted to white, middle-class—that is to say, bourgeois—transsexuals, who, since the 1980s, have paid out of pocket. (“I refer to a middle-class of transgender people in the specific sense of people with college degrees or more education; people working in skilled labor and the professions; and people who are culturally influential in terms of consumption and manners,” Gill-Peterson told me.) In the early 2000s, medical transition became increasingly available through private employer insurance, especially for employees of the American empire’s military and tech sectors.

Though the ACA was not explicitly written to expand trans healthcare, its passage in 2010 wound up doing just that. Section 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 Section 1557 to exclude nondiscrimination based on gender and sexuality. If elected, he could easily do it again; he could also just push to dismantle the ACA entirely, as he did in his first term. 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 commitment to maintaining a role for private health insurance, functionally blocking the implementation of a full single-payer healthcare system.

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.