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President Joe Biden addresses the nation from the Rose Garden of the White House in Washington, DC, on November 7, 2024 after Donald Trump wins the presidential election. In the aftermath of Donald Trump’s presidential victory, journalists and analysts have rushed to diagnose the causes of Vice President Kamala Harris’s defeat and the broader losses of the Democratic Party. One of the emerging theories is that voters felt that Democrats had drifted far from mainstream concerns by focusing too much on culture issues — particularly transgender rights. The GOP weaponized transgender rights on the campaign trail, pouring over $200 million into ads this cycle that painted Harris as out of step. “Kamala is for they/them. President Trump is for you,” blared one ad that launched in September. At rallies, Trump stoked fears with lies about gender-affirming surgery in schools, while promising to ban transgender women from sports. The Trump campaign maintains that their anti-trans ads resonated not only with Black and Latino men but also with moderate suburban white women concerned about school sports. Galvanize Action, a progressive organization focused on mobilizing moderate white women, did find that 53 percent of respondents on their most recent September survey believed people advocating for the rights of transgender people “have gone too far.”    After the election, some Democrats echoed the concern. “I don’t want to discriminate against anybody, but I don’t think biological boys should be playing in girls’ sports,” said Rep. Tom Suozzi, a New York moderate, in an interview with the New York Times, “Democrats aren’t saying that, and they should be.” Rep. Seth Moulton of Massachusetts made similar remarks: “I have two little girls. I don’t want them getting run over on the field by a male or formerly male athlete, but as a Democrat, I’m supposed to be afraid to say that.” Franklin Foer, a journalist for the Atlantic and author of a book on Joe Biden’s presidency, reported last week that some members of Biden’s inner circle were dissatisfied with Harris’s defense against right-wing accusations that she supported the most extreme version of transgender rights, including gender-affirming surgery for prisoners. Biden’s allies claimed that the president “never would have let such attacks stand” and would have “clearly rejected the idea of trans women competing in women’s sports.” While it will take time to fully understand why voters cast their ballots as they did, one thing is already clear: Neither Harris nor Biden made any effort to talk about what the Biden administration actually proposed to do on school sports.  What the Biden administration proposed on transgender athletes In 2023, over strong objections of activists on the right and left, the Biden administration announced a proposed change to Title IX, the law that prohibits discrimination based on sex in any federally funded educational program. Their suggested change would prohibit outright bans on transgender athletes, but would permit schools to restrict transgender students from participating if they could demonstrate that inclusion would harm “educational objectives” like fair competition and the prevention of injury.  This more nuanced stance marked the first time the Biden administration took the position that sex assigned at birth can matter in school sports, something hotly disputed by leading LGBTQ rights organizations. The proposed rule also reflected research that suggests sex differences emerge over time, so the standard for inclusion in high school should not necessarily be the same as that in younger grades. Contrary to the post-election grumblings from Biden allies in the Atlantic, the president has been virtually silent on his own administration’s proposal for the last 18 months. He’s never spoken about it, and it was never mentioned by any other Biden official, including in any White House briefing on transgender issues.  The White House declined to comment for this story. A spokesperson for the Education Department said their rulemaking process is still ongoing, as they consider the 150,000 public comments they received. “We do not have information to share today on a timeline,” they added.  In polling, voters consistently ranked transgender rights as a very low priority compared to other issues.  But there is some evidence that Republicans’ years of attacks have taken their toll on public opinion. Gallup found in 2023 that 69 percent of Americans believe transgender athletes should only be allowed to compete on sports teams that match their sex assigned at birth, an increase from the 62 percent who said the same in 2021.  Tellingly, Biden’s proposed policy on transgender athletes — allowing targeted restrictions for fairness and safety while rejecting blanket bans — would likely resonate more with average Americans than the hardline stances typically associated with Republicans, who leaned on transgender fearmongering in the midterms only to see their candidates flop, or Democrats, who many voters perceive as having no nuance on the topic at all. Yet the Biden administration’s reluctance to clearly communicate their middle-ground position left a vacuum that Republicans were happy to fill. It’s a dynamic that political observers say has become increasingly common: Democratic leaders stake out a position but, wary of internal rifts, default to strategic ambiguity even on issues where their stances might resonate with voters. “The White House could have said something in the election, they could have said Democrats want rules too,” said Lanae Erickson, the senior vice president for social policy at Third Way, a centrist think tank. “The number one big messaging advice from 2022 we had is that Democrats want sports to be fair and athletes to be safe.” The Biden administration’s proposed school sports rule in 2023 marked a shift from its first two years Joe Biden has long stood out for his support of transgender rights. In 2012, as vice president, he called it “the civil rights issue of our time” — something he reiterated again while campaigning for his own presidential run in 2020. He named passing the Equality Act, an LGBTQ anti-discrimination bill, a top legislative priority, and on his first day in office issued a sweeping executive order that called on all federal agencies to review their rules to ensure that any sex discrimination protection includes sexual orientation and gender identity, too.   As the Biden administration prioritized LGBTQ rights, social conservatives were in the midst of shifting their focus to new cultural battles following their decisive losses on marriage for same-sex couples both at the Supreme Court in 2015 and in the court of public opinion. Right-wing activists did not hide that they were searching for a new galvanizing cause to rally donors and grassroots voters. “We threw everything at the wall,” Terry Schilling, the president of American Principles Project, a social conservative advocacy group, told the New York Times.  While their early efforts to focus on bathroom bans backfired, Schilling’s group discovered in 2019 that focusing on school sports bans appeared much more effective, even though the CDC had found just 1.8 percent of high school students even identified as transgender. In 2020, Idaho became the first state to ban transgender girls from school sports and within four years, half of all states had passed similar laws, as well as laws banning gender-affirming health care. “It happened super fast. It came out of nowhere,” said Erickson of Third Way. “People weren’t prepared to deal with it because it wasn’t on the radar.”“Athletes proved potent for them because there’s always winners and losers in sports,” added Gillian Branstetter, a communications strategist with the American Civil Liberties Union (ACLU). “And that’s not a particularly new tool for the right.”  In terms of policy, the Biden administration initially staked out a position that said there’s no legitimate basis to discriminate based on sex differences. In 2021, Biden’s Justice Department intervened in a lawsuit filed by parents of an 11-year-old transgender girl against the state of West Virginia, affirming this view.“[West Virginia] cannot point to any valid evidence that allowing transgender girls to participate on girls’ sports teams endangers girls’ athletic opportunities,” said the DOJ in its filing. “Instead, the State legislated based on misconceptions and overbroad assumptions about transgender girls.” While praised by major LGBTQ groups like the Human Rights Campaign, this position obscured quieter disagreement among transgender leaders. Some questioned whether sports participation should be a top priority for the movement, while others doubted whether litigation was the best approach for advancing inclusion, given the state of public opinion. The Justice Department’s position also masked divides within the Democratic Party. Though it’s a complex topic and more research is needed, some existing scientific evidence suggests that transgender girls and women who do not suppress testosterone can have advantages in sports, particularly if they have gone through male puberty.The West Virginia lawsuit wasn’t the only federal suit in the works. Happening at the same time was another case involving two transgender girls that was quickly drawing national attention. In response to Terry Miller and Andraya Yearwood winning multiple state track titles in Connecticut, competitors’ parents and the Christian right-wing legal organization Alliance Defending Freedom filed a lawsuit against Connecticut’s policy of including transgender athletes. Though initially dismissed in 2021, a federal judge just this month said the Title IX case could proceed. As more of these politically charged lawsuits and bills mounted, the Biden administration announced it would be delaying its proposed changes to Title IX, despite its Day 1 executive order. Sources involved said the delay was largely understood as a political move driven by the upcoming midterm elections. When the Education Department finally released its proposed school sports rule in 2023, its language represented more of a compromise.   The rule marked the Biden administration’s first time saying that differences depending on sex assigned at birth can matter in school sports and schools can discriminate in some cases, while also saying schools do not have to — thus permitting blue states like Connecticut to continue with existing policy. While its merits were debated, the federal proposal was on the table. “The draft regulation recognizes that there are real sex differences and that these matter in competition,” Doriane Coleman, a law professor at Duke University who focuses on sports and gender, told Vox. “For the progressive wing of the Democratic Party, which takes the position that all sex differences are just myth and stereotype, that was a big, maybe even treasonous move.” Biden, Harris, and the Democratic Party never talked about the school sports rule after it was proposed Even as conservatives barraged Democrats with attacks that they were extremists on school sports, the White House and then later the Harris campaign never sought to talk about the direction they thought Title IX policy ought to go.  Sources with close knowledge of the White House’s thinking, speaking on the condition of anonymity, told Vox the administration worried that talking about the rule would have unintended consequences for transgender individuals already facing threats, and they didn’t want to give political fodder for Republicans to twist their words. So they said nothing.  Some progressive communications strategists warned against generally staying silent on transgender rights. We Make the Future Action and ASO Communication tested different strategies and found messaging that didn’t directly reference transgender people tended to weaken support for progressive positions among certain voter groups who were otherwise confronted with anti-trans ads. Or, put differently, saying nothing could hurt more than saying something proactive.  “When Democrats are silent about race or immigrants or trans people, all that conflicted voters hear are the siren songs of hate peddling from Republicans about said ‘other,’” Anat Shenker-Osorio, who led the messaging research, told Vox. “Ignoring doesn’t make the attack go away. It makes it all that voters hear about the topic.”Erickson of Third Way agreed with this critique. In addition to not wanting to get yelled at by progressive leaders on Twitter, she said, Democrats believed they should avoid talking about transgender rights to change the subject. “I think that is so idiotic, especially when the issue is high-salience,” she stressed, emphasizing that leaders could have focused on shared values of freedom, dignity, and privacy. Mara Keisling, a longtime transgender advocate and founding director of the National Center for Transgender Equality, told Vox she wasn’t bothered that Harris hadn’t focused on transgender people on the campaign trail and that it’s understandable Harris would prioritize issues that mattered to all voters.  “It’s more important to me who won the election than whether or not trans people are mentioned,” Keisling said. On the question of where the Biden administration was headed on school sports participation, Kiesling said she just didn’t think people would care about the process of an Education Department rule. “They used to say in politics that if you’re talking about process, you’re losing,” she said.  Branstetter, with the ACLU, emphasized that it’s not as if national Democrats didn’t have good models to emulate when it comes to messaging, noting that red-state Democrats like those in Kansas, Oklahoma, and Arkansas have demonstrated clearly over the last half-decade how to stand up to anti-trans legislative attacks. “Democrats are overestimating the electoral potency and letting themselves get lost in the issue instead of framing the opposition’s attacks within the broader fight for equality,” she said.  Moving forward, a series of federal lawsuits — including the aforementioned Connecticut case and one the Supreme Court is set to hear next month — could affect how rules, laws, and guidelines on issues of transgender rights develop. The NCAA is also currently reviewing its own policies for transgender athletes at the college level.  Given the Supreme Court’s ruling earlier this year in Loper Bright Enterprises v. Raimondo, federal agencies may have far less leeway to make policy decisions of all kinds without Congress getting involved. My colleague Ian Millhiser called the ruling a “radical reordering of the US separation of powers” and “likely to be one of [the Court’s] most consequential modern-day decisions.” Coleman, of Duke Law, thinks the Loper Bright decision and broader changes in administrative law will mean the school sports issue ultimately gets decided legislatively, not in the courts.  Until then, though, the matter will likely continue to play out in politics. Democrats may be well-intentioned in seeking to avoid heated and sensitive issues, but their strategy of silence can fuel the perception that the party cannot craft politically viable solutions, and more importantly, contribute to the myth that there’s a major ongoing crisis in school sports.“There aren’t trans athletes everywhere beating women,” said Keisling. “There are a lot of 6-year-olds and 10-year-olds who just want to play soccer with their friends.” 

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Robert F. Kennedy Jr. speaks alongside former President Donald Trump at a campaign rally in Georgia in October 2024. | Jabin Botsford/The Washington Post Donald Trump announced Thursday that Robert F. Kennedy Jr. would be his nominee to lead the Department of Health and Human Services, setting the stage for a potentially radical remaking of the nation’s health care.  Kennedy’s nomination was not a surprise. Last month, Kennedy said Trump had promised him control of the department and its many subagencies, which include the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institutes of Health, the Centers for Medicare and Medicaid, and others. Trump himself pledged during the campaign to let Kennedy “go wild on health.” It’s a perplexing pick. Kennedy has spent decades spreading anti-vaccination pseudoscience, and the organization he leads, Children’s Health Defense, has been one of the foremost anti-vaccine advocacy groups in the US and abroad. His work in support of a Samoan anti-vaccine group helped fuel a wave of vaccine hesitancy in the island nation, leading to a 2019 measles epidemic that killed 83 people, most of them children. He’s expressed a range of other conspiracy-laden ideas about health: He says fluoride is industrial waste linked to a range of diseases, and suggested it should be removed from all US water systems. He has speculated that gender dysphoria may result from herbicide exposure and implied mass shootings are linked to antidepressants.  Kennedy does hold other views that align with many scientists: He traces America’s high levels of chronic disease to the widespread availability of highly processed, non-nutritious food, which he and nutrition policy experts blame in part on broken agriculture policy. He’s railed against corruption and conflicts of interest in the FDA’s drug approval process that favor big pharmaceutical companies over the interests of individuals — something economists, scientists, and consumer advocates agree on.  No matter where a person stands on the political spectrum, they can probably find something to agree with Kennedy on. He is the personification of the growing distrust of science and “the public health establishment” felt by many Americans in the post-pandemic era. HHS secretaries are usually seasoned bureaucrats with lots of experience moving policy through government agencies — a state insurance commissioner in Obama’s case or a tenured pharma executive in Trump’s first term. They typically understand how science is done and what it means for a health intervention to be grounded in evidence.  Kennedy doesn’t have that résumé — far from it. Now he’ll be in charge of much of US health care, which raises the question: How much damage can he actually do in this role? The answer will depend on a few things. First, he has to be confirmed by the Senate (unless the White House attempts to circumvent that chamber’s constitutional “advise and consent” powers) and Republicans have only a narrow majority. Even if Kennedy is confirmed, Trump has other important health care appointments to make — particularly for CMS, NIH, FDA, and CDC — and those people will hold sway over the administration’s health care agenda too. They could be in the Kennedy vein or, as we have seen with Trump’s foreign policy picks, they could be a mix of the conventional and the iconoclastic.  For now, however, Kennedy’s appointment is a watershed moment that could portend enormous changes to the American health system. Republicans in Congress will control the HHS budget, and Kennedy, if confirmed, could have broad discretion to pursue his Make America Healthy Again agenda with Trump’s blessing. If the Trump administration attempts to remove civil servants across the government, including the health agencies, decades of public health knowledge could be lost at the CDC, FDA, and elsewhere. It is uncertain if the Republican-dominated judiciary would step in to stop any of it. Here’s what we know about the Trump health department’s plans — and what hurdles may await them. What RFK can — and can’t — do on vaccines, briefly explained Over the last 30 years, vaccines have saved the lives of more than 1.1 million children in the US alone. Over the same period, they’ve also saved Americans $540 billion in direct health care costs and trillions in social costs. Routine vaccines protect American children from 16 diseases. Trump himself suggested blocking funding for local schools with vaccine requirements during the campaign, though the federal government has limited authority to do so. Despite Kennedy’s long history of anti-vaccine rhetoric, he said in early November that he wasn’t planning to take anyone’s vaccines away.  “People ought to have choice, and that choice ought to be informed by the best information,” Kennedy said in an interview with NBC News. “So I’m going to make sure scientific safety studies and efficacy are out there, and people can make individual assessments about whether that product is going to be good for them.”  However, a co-chair of Trump’s transition team recently said Kennedy hoped to access federal health data with the goal of proving vaccines are unsafe and pulling them from the American market. That’s not as easy to do as it sounds.  Undoing the approval of an already approved vaccine would require submitting evidence of harm that meets the FDA’s standards to prove harm, which simply doesn’t exist. Although a Trump-installed loyalist could theoretically rewrite the FDA’s standards, that would likely lead to opposition from the pharmaceutical companies that produce these vaccines. There would be a wave of expensive and prolonged lawsuits for the federal government.  Drug makers are also influential with Congress, which writes the law that sets pharmaceutical industry fees that cover nearly half of the FDA’s budget. That law will need to be reauthorized before the end of Trump’s term, setting up a potentially vicious fight if the two sides are at odds over vaccines.  There is a more realistic move Kennedy could take to address his concern about vaccine side effects: He could resuscitate the National Vaccine Program Office, which monitored vaccine safety with particular rigor but was shuttered under the first Trump presidency. Although it would be difficult to pull vaccines from the American market, and Kennedy says he won’t, there are other ways he could exert influence to reduce vaccine uptake.  Kennedy could try to influence the CDC. That agency has two important roles in promoting vaccines in the US: It convenes an Advisory Committee on Immunization Practices (ACIP) to provide expert recommendations on who should get which vaccines and at what age, and it administers the Vaccines for Children program, which provides free vaccines for children in low-income families.  The advisory committee is not mandated by federal law — it is convened only if the CDC wants it to be. A vaccine skeptic appointed to run the CDC under Kennedy could either staff the committee with anti-vaccination activists or dissolve it entirely. That would mean the agency would no longer provide widely accepted guidelines for vaccination that state health departments and hundreds of thousands of clinicians nationwide now rely on.  The Vaccines for Children program is funded by a pot of money that Congress sets aside for the CDC every year. Kennedy could press Congress and the White House to simply cut that funding, ending the program entirely. That would leave low-income families having to pay out of pocket to vaccinate their children. Kennedy will also be ultimately responsible for two giant public insurance programs: Medicare, which covers seniors, and Medicaid, which is overseen by the states and covers low-income people. In both programs, the amount of money disbursed by the federal government is in part determined by how good of a job the states and private insurers do in vaccinating children and older adults enrolled in these programs. Kennedy could pressure the CMS administrator to eliminate that vaccination requirement, one reason Trump’s choice at CMS will be one to watch.  It’s not clear what the timeline would be to accomplish any of these tasks; there’s no precedent for a president and HHS secretary who are so openly hostile to US public health infrastructure assuming control of it. Even if it takes a while, there’s widespread concern that giving such a platform to someone who denies vaccine science could further degrade public trust not only in the vaccines, but in the many other health recommendations and interventions that together comprise American public health and health care. Already, more isolated outbreaks of measles and other diseases that had previously been stamped out by vaccines are occurring at the same time vaccination rates are slipping. Paul Offit, a pediatric infectious disease doctor who directs the Vaccine Education Center at the Children’s Hospital of Pennsylvania in Philadelphia, said Kennedy has had such a big platform for so long that it’s unlikely he’ll be able to scare people about vaccines more than he already has. It’s in delivering the vaccines through programs like Vaccines for Children where he could perhaps do the damage: “If he were able to disrupt that, that would be a problem.” Can RFK Jr. really remove fluoride from US water? The US began fluoridating drinking water in 1945. An estimated 209 million Americans now drink tap water that contains added fluoride. The intervention is considered a historic public health win: It dramatically reduces tooth decay in children and also reduces tooth loss in adults.  Kennedy, however, has said that he would immediately advise the removal of fluoride from local water supplies. Why? Because he is exaggerating the actual risk.   Most of the fluoride and US tap water is added by water utility companies, but some tap water contains naturally occurring fluoride it absorbs from the local water table. The resulting high-fluoride tap water, which about 2 million Americans drink, contains about twice the amount of fluoride the US government recommends. According to a recent report from the US National Toxicology Program, drinking high-fluoride water might be linked to slightly lower IQ scores — by 2 to 5 points in some children — though IQ scores are an uncertain measure of intelligence.  However, there is no indication that tap water containing normal fluoride levels poses this risk — and its benefits to children’s and adult’s dental health are immense. The decision to fluoridate water is one that happens at the state and local level, which is why Kennedy could only advise fluoride’s removal. However, his leadership at HHS could give an opening to anti-fluoride action at the state level, where Republican leaders are increasingly hostile to what had been settled public health practices. Kennedy’s “Make America Healthy Again” campaign on food and chronic diseases Kennedy has called for a campaign against chronic disease that he’s branded as “Make America Healthy Again.” It is an ambiguous and wide-ranging platform, but the consistent theme is undoing what Kennedy sees as Big Pharma and Big Agriculture’s undue influence on what Americans eat and how they manage their health over time. Some of the ideas share the same pseudoscience as Kennedy’s views on vaccines. Kennedy recently said on social media that the FDA had “waged a war on public health” by “aggressive suppression” of Americans’ access to raw milk, among other things. States aren’t required to pasteurize milk, but the FDA requires milk sold across state lines to be pasteurized. Despite raw milk’s risk of causing life-threatening diarrheal diseases (and now, bird flu), states can already carve out exceptions that allow their residents to drink it.  Some of Kennedy’s ideas about food are more rooted in reality. For example, his take on nutrition’s role in chronic disease: He has correctly noted that the US has developed a terrible record on preventing diabetes, heart disease, and unhealthy weight, and places the blame where nutritional experts do — on permissive government policies and dietary guidelines that promote eating lots of ultra-processed foods and low levels of physical activity in schools.  As part of his fight against ultra-processed foods, Kennedy recently said he wants to do away with entire departments at the FDA, including the Center for Food Safety and Applied Nutrition. According to recent reporting in Science, he could indeed pressure whoever is appointed to lead the agency to eliminate that center, which makes Trump’s choice for FDA commissioner a critical one in setting his administration’s public health agenda.  However, if Kennedy wants to restrict the use of already-approved food additives, he needs more resources — not fewer: The process involves rigorous reviews of data, issuing public warnings, and actively monitoring the food supply. If Kennedy succeeded in closing the food safety office, that would reduce the number of people who could be dedicated to the job, making it harder rather than easier to rein in the use of these products. Other actions could be taken by the Trump administration to reduce the amount of ultra-processed food in the American food supply, but many of them would be taken outside of HHS. The US Department of Agriculture sets the guidelines that govern school lunch programs, which means much of what children eat is determined by that agency; Trump has not yet nominated a USDA commissioner. The USDA is also primarily responsible for overseeing factory farming, another industry Kennedy has heavily criticized throughout his public career and pledged to target if he were to take a role in the federal government. He would likely need to work with the USDA to follow through.  Kennedy is correct that food safety regulation in the US is currently a mess, says David Acheson, an infectious disease doctor who has led food safety efforts at both the USDA and the FDA. Meat, poultry, and egg plants are inspected daily under the auspices of the USDA, while every other kind of food production facility — including the farms whose produce is responsible for most of the food-borne illness in the US and the nation’s countless other industrial food manufacturers — are inspected by FDA inspectors at most once a year.  It would make far more sense to unify these functions under one agency and harmonize the frequency of food production facility inspections so none are falling through the cracks. That is the kind of organizational shake-up that could actually make a difference.   Acheson would also like to see Kennedy take on the FDA’s process for regulating supplements, which are currently subject to lax oversight despite obvious health risks. What happens to NIH in a second Trump term? At a town hall earlier this year, before dropping out of the race for president, Kennedy said that if elected, he’d tell the National Institutes of Health to pause drug development and infectious diseases for eight years and instead focus on chronic diseases. He also pledged during his own campaign for president that he would block “gain of function” research — in which scientists purposefully make viruses more dangerous in hopes of learning how to better combat them — that has come under more scrutiny since the pandemic.  Apart from the fact that the NIH already spends about $20 billion annually on chronic disease, this would be disastrous: The basic research the agency funds and conducts in its own institutes lays the groundwork for therapies pharmaceutical companies develop to treat most medical conditions.  Kennedy has called for firing 600 of the agency’s nearly 19,000 employees and replacing them with new ones, who presumably would be more keen to carry out his priorities. Conservatives have also floated restructuring the NIH, and Trump proposed cutting its $48 billion budget during his first term.

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