The Murky Business of Transgender Medicine

Did Texas Children’s Hospital commit fraud to pay for child sex-change procedures?

The “gender-affirming care” business has always had an aura of madness around it. Wielding the authority of white coats and prestigious degrees, doctors have convinced large swaths of the public that some children are “born in the wrong body.” The solution? Stop puberty, prescribe cross-sex hormones, and then, with the stroke of a knife, remove body parts—most commonly breasts, less frequently genitalia.

These medical practices use scientific rhetoric to affirm what is, at bottom, an ideological program. And gender activists have been successful enough at capturing the legitimizing institutions—medical societies, regulatory bodies, and teaching hospitals—to repel most challenges to the burgeoning child sex-change industry. 

Now, though, the consensus appears to be shifting. European governments have backed away from many of these dubious procedures. In England, the Cass Review has raised grave questions about the scientific evidence behind “gender-affirming care.” In the United States, the public has turned decisively against the use of puberty blockers and gender surgeries on minors, with some state legislatures banning the practice. 

I have reported on one of these programs, the pediatric gender clinic at Texas Children’s Hospital. Last year, I published an investigation demonstrating that, though it had promised to shut down its program, Texas Children’s had continued to administer hormone drugs to children as young as 11. Following the story, the state attorney general launched an investigation, and state legislators passed a bill, SB 14, prohibiting all transgender medical interventions on minors.

While these scandals caught the headlines, another story involving the same institution was brewing in the background: medical fraud. 

According to a new whistleblower, doctors at Texas Children’s Hospital were willing to falsify medical records and break the law to keep practicing “gender-affirming care.” Caught in the wave of ideological fervor, two of the hospital’s prominent physicians, Richard Ogden Roberts and David Paul, cut corners and, according to the whistleblower, committed Medicaid fraud to secure funds for the hospital’s child sex-change program.

(Texas Children’s Hospital, Roberts, and Paul did not respond to a request for comment.)

This is a story of fanaticism, hubris, and the murky business of transgender medicine. It would have remained hidden, except for the courage of two people inside the hospital, a surgeon named Eithan Haim and a nurse who has now decided to come forward. Both have risked much to alert the public to the barbarism that is occurring at the nation’s largest, and arguably most prestigious, children’s hospital.

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Some years ago, Vanessa Sivadge thought she had it made, having just accepted a position as a registered nurse at Texas Children’s Hospital. She had wanted to be a nurse since high school and felt a sense of joy in helping children. 

But her feelings toward Texas Children’s didn’t last. Beginning in 2021, Sivadge saw a dramatic rise in the number of “transgender children” treated at the hospital. These patients struggled with various problems: depression, anxiety, addiction, suicide attempts, physical abuse, and discomfort with puberty. But rather than deal with these underlying psychological conditions, Sivadge says, doctors at the hospital would diagnose them with “gender dysphoria” and assign them to a regimen of “gender-affirming care.” 

The practice made Sivadge recoil. “In the cardiac clinic, we were taking sick kids and making them better,” she says. “In the transgender clinic, it was the opposite. We were harming these kids.”

Then, the following year, she breathed a sigh of relief. Under pressure from the state attorney general, Ken Paxton, Texas Children’s CEO Mark Wallace said that he was shutting down the child gender clinic. But it wasn’t true. Mere days later, it had secretly reopened for business.

And business was booming. Doctors, including Roberts, Paul, and Kristy Rialon, were managing dozens of pediatric sex-change cases, performing surgeries, blocking puberty, implanting hormone devices, and making specialty referrals. They were motivated not only by ideology, but by hope for prestige: they were saviors of the oppressed, the vanguard of gender medicine.

Sivadge soon had seen enough. She read my investigative report exposing Texas Children’s sex-change program, which relied on testimony from Haim, and reached out to share her own observations. 

“I work very closely with this provider, Dr. Richard Roberts. I’ve been in the room with him when he speaks with these patients,” she told me in an interview. “Dr. Roberts is extremely encouraging of their transition and will essentially do whatever he can to make sure that they are happy, at least externally happy. Because I am absolutely certain that they are not internally happy. He is very accommodating. He does whatever they want. Essentially, there is no critical analysis of the process.”

 In Sivadge’s view, Roberts and other providers were manipulating patients into accepting “gender-affirming care.” When parents objected, the doctors bulldozed them, she claims. Some families, she believed, feared that the hospital would call Child Protective Services if they dissented.

Then, two months after I spoke with her for that story, Sivadge called me in a panic. The FBI had sent two special agents, Paul Nixon and David McBride, to her home. The agents knocked on the door, asked her about “some of the things that have been going on at [her] work lately,” and then asked to enter her home. She was terrified. (The FBI declined to comment.) 

The agents told Sivadge that she was a “person of interest” in an investigation targeting the whistleblower who had exposed the child sex-change program. They told her that the whistleblower had broken federal privacy laws. “They threatened me,” Sivadge said. “They promised they would make life difficult for me if I was trying to protect the leaker. They said I was ‘not safe’ at work and claimed that someone at my workplace had given my name to the FBI.” 

The authorities—the FBI, the hospital, and, as Sivadge would later discover, federal prosecutors—were all circling the story. Both the Department of Justice and the hospital leadership were ideologically committed to “transgender medicine.” They had been embarrassed by the investigation that had exposed their actions, and they were looking for revenge.

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Things went quiet for a while afterward. Sivadge resumed her work as a nurse, and the FBI did not reappear.

Texas Children’s Hospital continued its sex-change program but focused instead on patients who had reached the legal age of 18. Sivadge saw the same terrible medical regimen being prescribed for these young adults: testosterone for girls, estrogen for boys, and referrals for specialty services. While Roberts and Paul had stopped providing sex-change procedures for minors, the gender clinic still overflowed with “transgender” teens.  

Sivadge’s duties as a nurse included providing medication refills and working with doctors to provide parents with information about treatment plans, scheduling, and diagnostics. She worked with patients’ charts and saw their complex psychological diagnoses and the treatments administered by the doctors.

Then Sivadge noticed discrepancies in the paperwork. After the FBI visit, she followed some of the medical charts for these patients and came to believe that doctors might be violating the law.

As Sivadge learned, Texas law forbade hospitals from billing Medicaid for transgender procedures. The Texas Medicaid Provider Procedures Manual has long stated that “sex change operations” are “not benefits of Texas Medicaid.” In 2021, Texas Medicaid officials told the Kaiser Family Foundation that this prohibition was not limited to genital surgeries but “explicitly excludes coverage of all gender affirming health services.” 

Transgender activist organizations and the popular media held this to be common knowledge. As the left-leaning Texas Tribune explained in 2023: “In Texas, Medicaid and the Children’s Health Insurance Program already don’t cover transition-related surgeries and prescription drugs like hormone therapies and puberty blockers.”

When reached for comment, a spokesman for Texas Health and Human Services confirmed that the state Medicaid program has “never covered ‘gender-affirming’ surgery or prescription drugs for the purpose of ‘gender-affirming’ care.” 

At Texas Children’s, as she was treating patients, Sivadge carefully scrutinized the treatments related to an alarming number of “transgender” teenagers under the care of Roberts and Paul, who, she came to believe, were unlawfully billing the state Medicaid program.

One patient, whom we’ll call Patient A, began treatment at Texas Children’s in 2022, at the age of 16. Patient A is a biological female who identified as “non-binary” and whose records claimed that she was “male.” This patient began treatment with Roberts, who approved a prescription for testosterone as part of the patient’s “gender-affirming” medical regimen.

During treatment, Roberts explained to Patient A the effects of testosterone, including masculinization and the suppression of fertility, and had her continue with testosterone injections. Roberts carefully monitored the progression of the desired characteristics for gender transition: voice deepening, facial hair, body hair. By the following year, Roberts increased the dosage of testosterone for Patient A, with the associated diagnosis of gender dysphoria.

Another patient, whom we’ll call Patient B, began care at Texas Children’s in 2022, also at the age of 16. Patient B is a biological male who identified as a female and whose records indicated the transgender identity, “female.” He arrived at the gender clinic under the care of Paul, already having begun a prescription of a testosterone blocker and estrogen, which served as a sex-change hormone.

Paul wanted to help Patient B feminize his body to conform to his desired gender identity. Patient B had increased the size of his breasts but was frustrated by the persistence of facial hair. Paul discussed changing the testosterone blocker and increasing the dose of estrogen in order to make progress with feminization. Patient B told Paul that he wanted his breasts to be larger, firmer, and more pressed together, with larger areolas. Paul adjusted Patient B’s estrogen prescription and discussed the possibility of breast implants.

Sivadge noticed another critical piece of information: Patient A and Patient B, like several other “transgender” patients, were enrolled in Texas Children’s Health Plan STAR, a “no-cost Medicaid managed care plan.”

Despite the law, which prohibited billing Medicaid for “gender-affirming care,” it appears that this was a standard practice at Texas Children’s Hospital. As Roberts himself admitted in a 2023 affidavit related to the lawsuit against SB 14, he had several patients in his transgender medicine program “who receive their health coverage through Medicaid.”

According to a legal expert with deep knowledge of Texas Medicaid law, the essential facts are as follows: Patients A and B had coverage through Texas Children’s Plan STAR; the doctors explicitly treated them for the purpose of “gender-affirming care”; and the standard practice would be for the hospital to submit this care for reimbursement through the state Medicaid program. It would be extremely unlikely, according to this expert, for the hospital to forgo this practice and, for example, cover the cost of its “gender-affirming care” program from its own budget.

“Based on the facts we have, the only reasonable conclusion is that Texas Children’s Hospital was using Texas Medicaid funds to pay for ‘gender-affirming care,’ contrary to Texas law,” said the legal expert.

For Sivadge, there was no doubt about what was happening. “The largest children’s hospital in the country is illegally billing Medicaid for transgender procedures,” she said. “It is evident that the hospital continues to believe it is above the law not just by concealing the existence of their transgender medicine program from the public, but by stealing from the federal government.”

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During this period, the politics of gender procedures were changing behind the scenes. Federal investigators were busy assembling information. A federal prosecutor, Tina Ansari, threatened the original whistleblower, Haim, with prosecution. And the hospital continued to churn through transgender patients. 

Then, earlier this month, the stakes intensified. Three heavily armed federal agents knocked on Haim’s door and gave him a summons. According to the documents, he had been indicted on four felony counts of violating medical privacy laws. If convicted, Haim faces the possibility of ten years in federal prison.

The Justice Department appears to be playing a cat-and-mouse game with those willing to challenge the legitimacy of transgender medicine. As public opinion shifts against “gender-affirming care,” Justice Department officials seem to be pursuing harder methods of ideological enforcement—investigating, threatening, and indicting whistleblowers. If you expose the barbarism that is happening in American gender clinics, the message seems to be, you risk imprisonment.

Sivadge, however, remains undeterred. “My faith and my gut, just knowing right from wrong, compels me,” she says. “I was born for this. I have no doubt this is what I am supposed to do.”

For her, it is personal. She witnessed and unwittingly participated in what she now believes to be, quoting a passage from the Bible, “deeds of evil and darkness.” She considers blowing the whistle a form of redemption, recalling a moment early on, in which Roberts asked her to teach a 16-year-old boy how to inject estrogen into his body to affirm a female identity. Later, Sivadge says, she realized what she had done: she had participated in a lie that would harm this boy. 

“I was told to do something I knew was wrong,” she says. “It made me sick that the lie called ‘gender-affirming care’ was being sold to parents and children and creating hugely lucrative profits in secret—and I was part of it.” 

Sivadge is not the only one feeling regret. Doctors, families, and political leaders are all starting to question the folly of child sex-change programs. The sense is growing that the public was sold a bill of goods—and that children are being put in grave danger. We have begun the painful process of recognition. The activist euphoria has worn off, the old rationalizations no longer suffice, and the bill has come due.

Texas Children’s Hospital is at the center of this national drama. Both sides—the “gender-affirming” doctors and the whistleblowers opposed to them—face enormous risk, including the loss of medical licenses and time in prison.

Some of those implicated in the scheme might escape with their reputations intact. Others might meet ruin. But a deeper lesson emerges, impervious to the ideological mania and the legal maneuvering that have precipitated this crisis: nature is not easily conquered, and its reckoning cannot be delayed forever.

This article was originally published in City Journal.